Provider Demographics
NPI:1497737050
Name:WILLIAMS, CONNIE S (LISW-SUPV)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:S
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LISW-SUPV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45015-1653
Mailing Address - Country:US
Mailing Address - Phone:513-892-4673
Mailing Address - Fax:513-737-1107
Practice Address - Street 1:302 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5037
Practice Address - Country:US
Practice Address - Phone:937-281-4673
Practice Address - Fax:937-318-1120
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLSW S 00052461041C0700X
OHI.0800334-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2272231Medicaid