Provider Demographics
NPI:1003381567
Name:WILLIAMS, KEJUAN SULLIVAN
Entity Type:Individual
Prefix:
First Name:KEJUAN
Middle Name:SULLIVAN
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 1:2534 KEY ST APT 3
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-4806
Mailing Address - Country:US
Mailing Address - Phone:313-693-0585
Mailing Address - Fax:
Practice Address - Street 1:690 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ROSSFORD
Practice Address - State:OH
Practice Address - Zip Code:43460-1221
Practice Address - Country:US
Practice Address - Phone:614-844-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2022-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIW452465778878OtherDRIVERS LICENSE NUMBER
OH2615030Medicaid