Basic Information
| Provider Information | |||||||||
| NPI: | 1760634299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | WAYMAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3210 FAIRHILL DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192560824 | ||||||||
| FaxNumber: | 9192560833 | ||||||||
| Practice Location | |||||||||
| Address1: | 3119-A LEAR DRIVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272158817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362295905 | ||||||||
| FaxNumber: | 3362295906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2008 | ||||||||
| LastUpdateDate: | 04/16/2009 | ||||||||
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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 | 101YP2500X | 7170 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6104024 | 05 | NC | MEDICAID |