Provider Demographics
NPI:1992973143
Name:WILLIAMS, MICHELLE ELIZABETH (OT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELIZABETH
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 MARIPOSA VISTA LN APT 207
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-0682
Mailing Address - Country:US
Mailing Address - Phone:215-805-1307
Mailing Address - Fax:
Practice Address - Street 1:150 SOUTHPARK BLVD STE 202
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5179
Practice Address - Country:US
Practice Address - Phone:904-217-3103
Practice Address - Fax:904-467-3422
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-11
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT20773225X00000X
CAOT 4671225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107822500Medicaid