Provider Demographics
NPI:1407223639
Name:WILLIAMS, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
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:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34220-0997
Mailing Address - Country:US
Mailing Address - Phone:941-776-4000
Mailing Address - Fax:941-776-4013
Practice Address - Street 1:5325 26TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-3012
Practice Address - Country:US
Practice Address - Phone:941-708-8500
Practice Address - Fax:941-708-8503
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002415900Medicaid