Basic Information
| Provider Information | |||||||||
| NPI: | 1265168629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | LATRELLE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.S, M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIAMS | ||||||||
| OtherFirstName: | KIM | ||||||||
| OtherMiddleName: | LATRELLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MARSHALL | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 501 OLD RICHMOND RD APT 522 | ||||||||
| Address2: | |||||||||
| City: | PORT WENTWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314079296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054017201 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 COMMERCIAL CT STE AVENUE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314063674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123524357 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2022 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.