Provider Demographics
NPI:1538622147
Name:WILLIAMS, MATTHEW M
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:M
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 S THOMAS ST STE C
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5328
Mailing Address - Country:US
Mailing Address - Phone:662-840-0974
Mailing Address - Fax:662-840-0388
Practice Address - Street 1:146 S THOMAS ST STE C
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-5328
Practice Address - Country:US
Practice Address - Phone:662-840-0974
Practice Address - Fax:662-840-0388
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-0296101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health