Basic Information
| Provider Information | |||||||||
| NPI: | 1396412003 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | JENELL | ||||||||
| MiddleName: | TIORA | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30000 HIVELEY ST | ||||||||
| Address2: | |||||||||
| City: | INKSTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481411089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347283400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30000 HIVELEY ST | ||||||||
| Address2: | |||||||||
| City: | INKSTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481411089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347283400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2021 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TM1800X | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities |
No ID Information.