Provider Demographics
NPI:1205150794
Name:WILLIAMS, MATTHEW BENJAMIN (PHD)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:BENJAMIN
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:MR
Other - First Name:MATT
Other - Middle Name:BENJAMIN
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1640 POWERS FERRY RD SE STE 100
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-5491
Mailing Address - Country:US
Mailing Address - Phone:770-953-0080
Mailing Address - Fax:
Practice Address - Street 1:1640 POWERS FERRY RD SE STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:770-953-0080
Practice Address - Fax:770-953-0031
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27584103T00000X
GAPSY004293103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1205150794Medicaid