Basic Information
| Provider Information | |||||||||
| NPI: | 1477925469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | MIA | ||||||||
| MiddleName: | WHITESIDE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITESIDE | ||||||||
| OtherFirstName: | MIA | ||||||||
| OtherMiddleName: | DESHAWN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5005 N PIEDRAS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799205002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157426382 | ||||||||
| FaxNumber: | 9157424890 | ||||||||
| Practice Location | |||||||||
| Address1: | 5005 N PIEDRAS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799205002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157426382 | ||||||||
| FaxNumber: | 9157424890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2015 | ||||||||
| LastUpdateDate: | 12/07/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C-09095 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 62608 | TX | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 62608 | 01 | TX | ASSOCIATES OF SOCIAL WORK BOARD | OTHER | C-09095 | 01 | NM | ASSOCIATES OF SOCIAL WORK BOARD | OTHER |