Provider Demographics
NPI:1740475987
Name:WILLIAMS, MARY KILKENNY (MFT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KILKENNY
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MFT
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 343
Mailing Address - Street 2:
Mailing Address - City:POINT ARENA
Mailing Address - State:CA
Mailing Address - Zip Code:95468-0343
Mailing Address - Country:US
Mailing Address - Phone:707-882-2477
Mailing Address - Fax:707-882-2477
Practice Address - Street 1:40400 MT VIEW RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CA
Practice Address - Zip Code:95459
Practice Address - Country:US
Practice Address - Phone:707-882-2477
Practice Address - Fax:702-882-2477
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT22544106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT225440OtherBLUE SHIELD