Basic Information
| Provider Information | |||||||||
| NPI: | 1619004173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17053 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923353574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093471300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17053 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923353574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093471300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | PSY12198 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | BQ806Y | 01 | CA | MEDICARE ID TYPE UNSPECIFIED | OTHER |