Provider Demographics
NPI:1568920585
Name:WILLIAMS, NIA NICOLE
Entity Type:Individual
Prefix:
First Name:NIA
Middle Name:NICOLE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 HONAKER AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4533
Mailing Address - Country:US
Mailing Address - Phone:757-502-3856
Mailing Address - Fax:
Practice Address - Street 1:640 INDEPENDENCE PKWY STE 400B
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5205
Practice Address - Country:US
Practice Address - Phone:757-267-9634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician