Provider Demographics
NPI:1609410026
Name:WILLIAMSON, CHARLOTTE MARIE
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:MARIE
Last Name:WILLIAMSON
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 1:360 POLK ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1623
Mailing Address - Country:US
Mailing Address - Phone:317-888-1557
Mailing Address - Fax:317-888-1571
Practice Address - Street 1:360 POLK ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1623
Practice Address - Country:US
Practice Address - Phone:317-888-1557
Practice Address - Fax:317-888-1571
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-19-37851103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
090992OtherDOB