Provider Demographics
NPI:1104953769
Name:WILLIAMS, DAVID JOHN (PHD, MP)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PHD, MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5608
Mailing Address - Country:US
Mailing Address - Phone:318-998-3511
Mailing Address - Fax:318-322-9492
Practice Address - Street 1:1410 ROYAL AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5608
Practice Address - Country:US
Practice Address - Phone:318-998-3511
Practice Address - Fax:318-322-9492
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMP.0953103TC0700X
LAMPAP.000033103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H133CP51Medicare PIN