Provider Demographics
NPI:1679136014
Name:WILLIAMSON, KELLI-JEAN NATASHA (DOH SERVICE PROVIDER)
Entity Type:Individual
Prefix:
First Name:KELLI-JEAN
Middle Name:NATASHA
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:DOH SERVICE PROVIDER
Other - Prefix:
Other - First Name:KELLI-JEAN
Other - Middle Name:NATASHA
Other - Last Name:DALLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DOH SERVICE PROVIDER
Mailing Address - Street 1:852C LELAND AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-2866
Mailing Address - Country:US
Mailing Address - Phone:347-615-1977
Mailing Address - Fax:
Practice Address - Street 1:852C LELAND AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2866
Practice Address - Country:US
Practice Address - Phone:347-615-1977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency