Provider Demographics
NPI:1205234358
Name:WILLIAMS, PETRONIA
Entity type:Individual
Prefix:
First Name:PETRONIA
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 1:401 16TH ST SE STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-7974
Mailing Address - Country:US
Mailing Address - Phone:507-516-0030
Mailing Address - Fax:
Practice Address - Street 1:401 16TH ST SE STE 100
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-7974
Practice Address - Country:US
Practice Address - Phone:803-536-1571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-05
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC413093Medicaid