Provider Demographics
NPI:1225346869
Name:WILLIAMS, ROSHAUNTA JACQUESE EVORA (BA AFRICAN AMERICAN)
Entity Type:Individual
Prefix:MRS
First Name:ROSHAUNTA
Middle Name:JACQUESE EVORA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:BA AFRICAN AMERICAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 HIGHWAY 169 N APT 153
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-3190
Mailing Address - Country:US
Mailing Address - Phone:763-807-9244
Mailing Address - Fax:
Practice Address - Street 1:3301 HIGHWAY 169 N APT 153
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3190
Practice Address - Country:US
Practice Address - Phone:763-807-9244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker