Basic Information
| Provider Information | |||||||||
| NPI: | 1639515133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | KABRENA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 N ROCKY POINT DR STE 650 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336075999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008920640 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5030 78TH AVE N STE 11 | ||||||||
| Address2: | |||||||||
| City: | PINELLAS PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275451273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2013 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-17-28646 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 021762400 | 05 | FL | MEDICAID |