Provider Demographics
NPI:1003470808
Name:WILLIAMS, SHANETTA S
Entity Type:Individual
Prefix:
First Name:SHANETTA
Middle Name:S
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANETTA
Other - Middle Name:S
Other - Last Name:MURRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:81 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-1410
Mailing Address - Country:US
Mailing Address - Phone:585-368-6900
Mailing Address - Fax:585-546-5806
Practice Address - Street 1:81 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608-1410
Practice Address - Country:US
Practice Address - Phone:585-368-6900
Practice Address - Fax:585-546-5806
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP07247101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health