Provider Demographics
NPI:1992459127
Name:WILLIAMS, MICHELLE DYNEICIA (BT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DYNEICIA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 GEMSTONE PL
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-8402
Mailing Address - Country:US
Mailing Address - Phone:251-786-0588
Mailing Address - Fax:
Practice Address - Street 1:240 GEMSTONE PL
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-8402
Practice Address - Country:US
Practice Address - Phone:251-786-0588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7252540106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician