1063661569 NPI number — DR. KELLEY MARTIN WILLIAMS PSY.D.

Table of content: DR. KELLEY MARTIN WILLIAMS PSY.D. (NPI 1063661569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063661569 NPI number — DR. KELLEY MARTIN WILLIAMS PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
KELLEY
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063661569
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16441 SPACE CENTER BLVD
Provider Second Line Business Mailing Address:
SUITE C-100
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-480-7554
Provider Business Mailing Address Fax Number:
281-480-4641

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16441 SPACE CENTER BLVD
Provider Second Line Business Practice Location Address:
SUITE C-100
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-480-7554
Provider Business Practice Location Address Fax Number:
281-480-4641
Provider Enumeration Date:
09/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC2200X , with the licence number:  34916 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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