Provider Demographics
NPI:1720267164
Name:WILLIAMS, MARLENE C (MT-BC)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:C
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 E EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-1635
Mailing Address - Country:US
Mailing Address - Phone:610-449-9669
Mailing Address - Fax:610-449-5566
Practice Address - Street 1:412 E EAGLE RD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-1635
Practice Address - Country:US
Practice Address - Phone:610-449-9669
Practice Address - Fax:610-449-5566
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA14559101Y00000X, 101YP2500X, 225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017128200001Medicaid