Provider Demographics
NPI:1073214482
Name:WILLIAMS, K'DAJAH
Entity Type:Individual
Prefix:
First Name:K'DAJAH
Middle Name:
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 1:7417 WILLOW WISP DR W
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-4448
Mailing Address - Country:US
Mailing Address - Phone:863-660-3611
Mailing Address - Fax:
Practice Address - Street 1:600 LAKE HOLLINGSWORTH DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-2364
Practice Address - Country:US
Practice Address - Phone:863-277-6201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician