Provider Demographics
NPI:1619692084
Name:WILLIAMS, MALISSA R
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:R
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 1:1451 NW 38TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-4555
Mailing Address - Country:US
Mailing Address - Phone:636-485-0797
Mailing Address - Fax:
Practice Address - Street 1:12802 JOHNSON DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66216-1645
Practice Address - Country:US
Practice Address - Phone:913-228-1407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-03963225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist