Provider Demographics
NPI:1801472469
Name:WILLIAMS, MATTIE
Entity type:Individual
Prefix:
First Name:MATTIE
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 1:1121 S DOUGLAS BLVD UNIT A
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-5210
Mailing Address - Country:US
Mailing Address - Phone:405-666-8174
Mailing Address - Fax:405-458-8019
Practice Address - Street 1:1121 S DOUGLAS BLVD UNIT A
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5210
Practice Address - Country:US
Practice Address - Phone:140-592-1589
Practice Address - Fax:405-458-8019
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-21-161141106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician