Provider Demographics
NPI:1871793497
Name:WILLIAMS, MYRNA B (PHD)
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:B
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5052
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27113-5052
Mailing Address - Country:US
Mailing Address - Phone:336-748-9114
Mailing Address - Fax:336-748-1040
Practice Address - Street 1:1530 MARTIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4936
Practice Address - Country:US
Practice Address - Phone:336-748-9114
Practice Address - Fax:336-748-1040
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-21
Last Update Date:2007-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0953103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC03764OtherBLUE CROSS/BLUE SHIELD
NC6000153Medicaid