Provider Demographics
NPI:1285874909
Name:WILLIAMS, FREDDIE LEE
Entity type:Individual
Prefix:MR
First Name:FREDDIE
Middle Name:LEE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14281
Mailing Address - Street 2:
Mailing Address - City:RESEARCH TRIANGLE PARK
Mailing Address - State:NC
Mailing Address - Zip Code:27709-4281
Mailing Address - Country:US
Mailing Address - Phone:919-479-6917
Mailing Address - Fax:919-471-3904
Practice Address - Street 1:3671 GUESS RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-6908
Practice Address - Country:US
Practice Address - Phone:919-251-9821
Practice Address - Fax:919-471-3904
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-21
Last Update Date:2009-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-032-468322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604362Medicaid