Provider Demographics
NPI:1134697105
Name:WILLIAMS, FREDRICKA
Entity Type:Individual
Prefix:
First Name:FREDRICKA
Middle Name:
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 1:920 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-2227
Mailing Address - Country:US
Mailing Address - Phone:850-901-7823
Mailing Address - Fax:
Practice Address - Street 1:920 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-2227
Practice Address - Country:US
Practice Address - Phone:850-901-7823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid