Basic Information
| Provider Information | |||||||||
| NPI: | 1285913616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | COLLETTE | ||||||||
| MiddleName: | RENAE | ||||||||
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| Credential: | BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 928 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921015514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6199773716 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 470 E 3RD ST STE C | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136205712 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2011 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.