Provider Demographics
NPI:1891676169
Name:WILLIAMS, KIADRA DESIREE
Entity type:Individual
Prefix:
First Name:KIADRA
Middle Name:DESIREE
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 1:2340 SOUTHERN MANOR RD
Mailing Address - Street 2:
Mailing Address - City:METTER
Mailing Address - State:GA
Mailing Address - Zip Code:30439-7613
Mailing Address - Country:US
Mailing Address - Phone:912-221-5250
Mailing Address - Fax:
Practice Address - Street 1:564 E MAIN ST APT 154
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30461-2575
Practice Address - Country:US
Practice Address - Phone:912-221-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-24-343362106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician