Provider Demographics
NPI:1942953823
Name:WILLIAMSON, EZRA BRANDON I (MA)
Entity Type:Individual
Prefix:
First Name:EZRA
Middle Name:BRANDON
Last Name:WILLIAMSON
Suffix:I
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-5103
Mailing Address - Country:US
Mailing Address - Phone:920-227-7078
Mailing Address - Fax:920-273-8847
Practice Address - Street 1:217 N MADISON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-5103
Practice Address - Country:US
Practice Address - Phone:920-227-7078
Practice Address - Fax:920-273-8847
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4713-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional