Basic Information
| Provider Information | |||||||||
| NPI: | 1679655922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1550 COLLEGE ST | ||||||||
| Address2: | A | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312070001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783015930 | ||||||||
| FaxNumber: | 4783015932 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 FIRST STREET | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783015930 | ||||||||
| FaxNumber: | 4783015932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 10/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY001108 | GA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 680006605 | 01 | GA | RAILROAD MEDICARE | OTHER | 000342933A | 05 | GA | MEDICAID |