Provider Demographics
NPI:1740772813
Name:WILLIAMS, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
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 1:5335 ROCKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-8118
Mailing Address - Country:US
Mailing Address - Phone:757-645-6176
Mailing Address - Fax:
Practice Address - Street 1:906 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-1128
Practice Address - Country:US
Practice Address - Phone:804-798-3291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000052235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty