Provider Demographics
NPI:1841343662
Name:WILLIAMS, MICHAEL JEROME (LPC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JEROME
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9155 HEMIS FAIR DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-4006
Mailing Address - Country:US
Mailing Address - Phone:314-898-5218
Mailing Address - Fax:
Practice Address - Street 1:9155 HEMIS FAIR DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-4006
Practice Address - Country:US
Practice Address - Phone:314-898-5218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000331101YP2500X
MO2004003080225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493267322Medicaid