Provider Demographics
NPI:1467916932
Name:WILLIAMS, MARK SIJUADE
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:SIJUADE
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 1:7102 VERONICA ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3833
Mailing Address - Country:US
Mailing Address - Phone:269-870-7957
Mailing Address - Fax:
Practice Address - Street 1:2549 JOLLY RD
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3678
Practice Address - Country:US
Practice Address - Phone:571-992-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician