Provider Demographics
NPI:1023522448
Name:WILLIAMS, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
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 1:2844 TRACELAND DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4200
Mailing Address - Country:US
Mailing Address - Phone:662-680-3148
Mailing Address - Fax:
Practice Address - Street 1:868 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:VAIDEN
Practice Address - State:MS
Practice Address - Zip Code:39176-5385
Practice Address - Country:US
Practice Address - Phone:662-728-6234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2473225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSOT2473OtherOT LICENSE MISSISSIPPI