Provider Demographics
NPI:1881082964
Name:WILLIAMS, MISTY L (MAC)
Entity type:Individual
Prefix:MS
First Name:MISTY
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 BROWNS TRACE RD
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:VT
Mailing Address - Zip Code:05465-2009
Mailing Address - Country:US
Mailing Address - Phone:802-238-5823
Mailing Address - Fax:
Practice Address - Street 1:1233 SHELBURNE RD STE 360
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7752
Practice Address - Country:US
Practice Address - Phone:802-238-5823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-24
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
VT225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171100000XOther Service ProvidersAcupuncturist