Provider Demographics
NPI:1720206188
Name:WILLIAMS, KETTISHA ANNETRICE (BA)
Entity Type:Individual
Prefix:MRS
First Name:KETTISHA
Middle Name:ANNETRICE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 GLENDALE CIR
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MS
Mailing Address - Zip Code:39730-2903
Mailing Address - Country:US
Mailing Address - Phone:662-369-4619
Mailing Address - Fax:
Practice Address - Street 1:2434 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-6942
Practice Address - Country:US
Practice Address - Phone:662-844-1717
Practice Address - Fax:662-680-6416
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health