Provider Demographics
NPI:1508059551
Name:WILLIAMS, SUE ELLEN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SUE
Middle Name:ELLEN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5305 WATERMILL LN
Mailing Address - Street 2:APT 204
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7808
Mailing Address - Country:US
Mailing Address - Phone:321-720-7765
Mailing Address - Fax:321-567-4279
Practice Address - Street 1:772 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-4955
Practice Address - Country:US
Practice Address - Phone:321-267-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA46181225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist