Provider Demographics
NPI:1023140647
Name:WILLIAMS, MIA LYNETTE
Entity type:Individual
Prefix:MISS
First Name:MIA
Middle Name:LYNETTE
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 1:2500 E FOOTHILL BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-7102
Mailing Address - Country:US
Mailing Address - Phone:626-395-7100
Mailing Address - Fax:
Practice Address - Street 1:2500 E FOOTHILL BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-7102
Practice Address - Country:US
Practice Address - Phone:626-676-0803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91018106H00000X
225400000X
CA142858106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner