Provider Demographics
NPI:1205141710
Name:WITHERS, WILLIAM
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:WITHERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 FRANDORSON CIR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-2688
Mailing Address - Country:US
Mailing Address - Phone:813-641-3565
Mailing Address - Fax:813-640-3560
Practice Address - Street 1:400 FRANDORSON CIR
Practice Address - Street 2:SUITE 103
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-2688
Practice Address - Country:US
Practice Address - Phone:813-641-3565
Practice Address - Fax:813-640-3560
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH3516101YM0800X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766864300Medicaid