Basic Information
| Provider Information | |||||||||
| NPI: | 1659857647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | LORRAINE | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | CDCA 169900 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2447 NEBRASKA AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436073531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192554444 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3170 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436062945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5673167253 | ||||||||
| FaxNumber: | 5673167232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2018 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | OH | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | CDCA169900 | OH | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 0305498 | 05 | OH | MEDICAID |