Basic Information
| Provider Information | |||||||||
| NPI: | 1609192582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCAS, LPCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 665 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271012701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367258389 | ||||||||
| FaxNumber: | 3367256628 | ||||||||
| Practice Location | |||||||||
| Address1: | 665 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271012701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367258389 | ||||||||
| FaxNumber: | 3367256628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2010 | ||||||||
| LastUpdateDate: | 02/07/2013 | ||||||||
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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 | 101YP2500X | A7828 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 1600 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.