Provider Demographics
NPI:1295393643
Name:WILLIAMS, TINA K
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:K
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 1:189 VILLAGE PASS
Mailing Address - Street 2:
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666-1713
Mailing Address - Country:US
Mailing Address - Phone:770-542-7090
Mailing Address - Fax:
Practice Address - Street 1:189 VILLAGE PASS
Practice Address - Street 2:
Practice Address - City:STATHAM
Practice Address - State:GA
Practice Address - Zip Code:30666-1713
Practice Address - Country:US
Practice Address - Phone:770-542-7090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician