Provider Demographics
NPI:1821687740
Name:WILLIAMS, WANDA FAYE
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:FAYE
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:PO BOX 343
Mailing Address - Street 2:
Mailing Address - City:HOLLANDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38748-0343
Mailing Address - Country:US
Mailing Address - Phone:662-347-3969
Mailing Address - Fax:
Practice Address - Street 1:716 ROSENWALD ST
Practice Address - Street 2:
Practice Address - City:HOLLANDALE
Practice Address - State:MS
Practice Address - Zip Code:38748-3130
Practice Address - Country:US
Practice Address - Phone:662-347-3969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNBSW00000009501164319103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0000000000000Medicaid