Basic Information
Provider Information | |||||||||
NPI: | 1437209525 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLIAMS | ||||||||
FirstName: | DEBORAH | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1814 W 500 N | ||||||||
Address2: |   | ||||||||
City: | MARION | ||||||||
State: | IN | ||||||||
PostalCode: | 469529107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7656629971 | ||||||||
FaxNumber: | 7656516563 | ||||||||
Practice Location | |||||||||
Address1: | 1091 CENTRAL AVE | ||||||||
Address2: |   | ||||||||
City: | WABASH | ||||||||
State: | IN | ||||||||
PostalCode: | 469921526 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2605634407 | ||||||||
FaxNumber: | 2605636440 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2007 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34003856A | IN | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | IN0017671 | 01 | IN | TRICARE PROVIDER ID | OTHER | 000000004027 | 01 | IN | MPLAN ID | OTHER | 000000317611 | 01 | IN | GENCORP PROVIDER ID | OTHER | 0007186320 | 01 | IN | AETNA PROVIDER ID | OTHER | 088367428001 | 01 | IN | GENERAL LISCENCE # | OTHER | 000000183247 | 01 | IN | ANTHEM PROVIDER ID | OTHER |