Provider Demographics
NPI:1316461544
Name:WILLIAMS, MCKEVIN
Entity type:Individual
Prefix:
First Name:MCKEVIN
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 GLENDALE AVE NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-7039
Mailing Address - Country:US
Mailing Address - Phone:321-266-8939
Mailing Address - Fax:
Practice Address - Street 1:3260 N HARBOR CITY BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6203
Practice Address - Country:US
Practice Address - Phone:321-255-2260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-30
Last Update Date:2017-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10059224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant