Provider Demographics
NPI:1932677341
Name:WILLIAMS, LARAE NICHOLE (OC60901234)
Entity Type:Individual
Prefix:MS
First Name:LARAE
Middle Name:NICHOLE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:OC60901234
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19418 26TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-3415
Mailing Address - Country:US
Mailing Address - Phone:253-882-9852
Mailing Address - Fax:
Practice Address - Street 1:1010 S 336TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6385
Practice Address - Country:US
Practice Address - Phone:253-835-5769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60901234224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant