Provider Demographics
NPI:1518274695
Name:WILLIAMS, CYSHELLE (QPBS)
Entity Type:Individual
Prefix:
First Name:CYSHELLE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:QPBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 PINE NEEDLE CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2463
Mailing Address - Country:US
Mailing Address - Phone:910-691-7843
Mailing Address - Fax:
Practice Address - Street 1:4604 PINE NEEDLE CT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2463
Practice Address - Country:US
Practice Address - Phone:910-691-7843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-026-901320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities