Provider Demographics
NPI:1467499780
Name:WILLIAMS, TASHA H (PHD)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:H
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11104 PARKVIEW CIRCLE DR
Mailing Address - Street 2:STE 110
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1730
Mailing Address - Country:US
Mailing Address - Phone:260-460-3100
Mailing Address - Fax:260-460-3130
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR
Practice Address - Street 2:STE 110
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-460-3100
Practice Address - Fax:260-460-3130
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042081A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200816640Medicaid
INP00399217OtherRR MEDICARE
OH2705719Medicaid
INP00399217Medicare PIN
INP00399217OtherRR MEDICARE
IN200816640Medicaid
OH2705719Medicaid