Basic Information
| Provider Information | |||||||||
| NPI: | 1194951152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | RODGERS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT TRAINEE | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 12450 VAN NUYS BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PACOIMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913311393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1889611618 | ||||||||
| FaxNumber: | 8188965069 | ||||||||
| Practice Location | |||||||||
| Address1: | 12450 VAN NUYS BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PACOIMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913311393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1889611618 | ||||||||
| FaxNumber: | 8188965069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2009 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225C00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor |
ID Information
| ID | Type | State | Issuer | Description | 7068 | 05 | CA | MEDICAID | 7420 | 05 | CA | MEDICAID | 6758 | 05 | CA | MEDICAID |