Provider Demographics
NPI:1689047128
Name:WILLIAMS, TREVIS (MED)
Entity Type:Individual
Prefix:MRS
First Name:TREVIS
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MRS
Other - First Name:TREVIS
Other - Middle Name:
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED
Mailing Address - Street 1:126 ANNA ST
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-6011
Mailing Address - Country:US
Mailing Address - Phone:985-503-4592
Mailing Address - Fax:
Practice Address - Street 1:126 ANNA ST
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-6011
Practice Address - Country:US
Practice Address - Phone:985-503-4592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAB082688222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist