Provider Demographics
NPI:1336236637
Name:WILLIAMS, BLANCHE MCCOOL (PH D)
Entity type:Individual
Prefix:
First Name:BLANCHE
Middle Name:MCCOOL
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6817 SOUTHPOINT PKWY STE 2401
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8200
Mailing Address - Country:US
Mailing Address - Phone:904-399-0324
Mailing Address - Fax:
Practice Address - Street 1:6817 SOUTHPOINT PKWY STE 2401
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8200
Practice Address - Country:US
Practice Address - Phone:904-399-0324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002840103T00000X
FLPY10054103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007701942Medicaid
VAR42007Medicare UPIN
VA680001403Medicare ID - Type Unspecified