Provider Demographics
NPI:1730323163
Name:WILLIAMS, AMY BETH
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:BETH
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 1:730 N CARPENTER RD
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2273
Mailing Address - Country:US
Mailing Address - Phone:321-403-8709
Mailing Address - Fax:
Practice Address - Street 1:730 N CARPENTER RD
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2273
Practice Address - Country:US
Practice Address - Phone:321-403-8709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-29
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9151235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000821300Medicaid