Basic Information
| Provider Information | |||||||||
| NPI: | 1588184857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS COLLINS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | Y | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5154 STAGE RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381343118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013729133 | ||||||||
| FaxNumber: | 9013721015 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 MADISON AVE STE 922 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381633118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014485630 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | P2914 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | Q034995 | 05 | TN | MEDICAID | 08650505 | 05 | MS | MEDICAID | 228484719 | 05 | AR | MEDICAID |