Provider Demographics
NPI:1205457488
Name:WILLIAMS, MINNIE MICHELLE (BS, SLA)
Entity type:Individual
Prefix:PROF
First Name:MINNIE
Middle Name:MICHELLE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:BS, SLA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:AR
Mailing Address - Zip Code:72352-0155
Mailing Address - Country:US
Mailing Address - Phone:870-995-0870
Mailing Address - Fax:
Practice Address - Street 1:305 VALLEY DR
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:AR
Practice Address - Zip Code:72342-1505
Practice Address - Country:US
Practice Address - Phone:870-338-4425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR03-0057Medicaid