Provider Demographics
NPI:1821041021
Name:WILLIAMSON, MARY TODD (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TODD
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:3217 S PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3639
Practice Address - Country:US
Practice Address - Phone:573-884-7733
Practice Address - Fax:573-884-5559
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01775103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO680007308OtherRR MEDICARE
MOP00415787OtherRAILROAD MEDICARE
MO498143601Medicaid
MOP00415787OtherRAILROAD MEDICARE
MO223425236Medicare PIN
S28361Medicare UPIN