Provider Demographics
NPI:1528890456
Name:WILLIAMS, TYDAHJA MALIACHRISTINE
Entity type:Individual
Prefix:
First Name:TYDAHJA
Middle Name:MALIACHRISTINE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 ENRIGHT RD FL 2
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2309
Mailing Address - Country:US
Mailing Address - Phone:929-432-9725
Mailing Address - Fax:
Practice Address - Street 1:17515 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-5503
Practice Address - Country:US
Practice Address - Phone:718-632-3275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26612101Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor