Basic Information
| Provider Information | |||||||||
| NPI: | 1255848735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RBT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOCKWOOD | ||||||||
| OtherFirstName: | MONIQUE | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RBT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 125 E NASA BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212654409 | ||||||||
| FaxNumber: | 3217656434 | ||||||||
| Practice Location | |||||||||
| Address1: | 2180 JULIAN AVE NE | ||||||||
| Address2: | |||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213726813 | ||||||||
| FaxNumber: | 3217656434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2018 | ||||||||
| LastUpdateDate: | 02/08/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-19-78001 | FL | Y |
ID Information
| ID | Type | State | Issuer | Description | 023607500 | 05 | FL | MEDICAID |