Provider Demographics
NPI:1033449350
Name:WILLIAMS, MARY T
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
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 1:340 CAMPBELL DR
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3731
Mailing Address - Country:US
Mailing Address - Phone:321-768-6800
Mailing Address - Fax:321-768-6858
Practice Address - Street 1:1800 PENN ST STE 12
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2625
Practice Address - Country:US
Practice Address - Phone:321-768-6800
Practice Address - Fax:321-768-6858
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4737235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist