Provider Demographics
NPI:1992550883
Name:WILLIAMS, KRYSTAL RENEA
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:RENEA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7106 LILAC DR
Mailing Address - Street 2:
Mailing Address - City:VENUS
Mailing Address - State:TX
Mailing Address - Zip Code:76084-3751
Mailing Address - Country:US
Mailing Address - Phone:414-588-7306
Mailing Address - Fax:
Practice Address - Street 1:5473 BLAIR RD STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4227
Practice Address - Country:US
Practice Address - Phone:414-588-7306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities