Provider Demographics
NPI:1427701366
Name:WILLIAMS, GARY LEWALL (PEER RECOVERY COACH)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:LEWALL
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PEER RECOVERY COACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15217 SAN BERNARDINO AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-5327
Mailing Address - Country:US
Mailing Address - Phone:951-643-2150
Mailing Address - Fax:
Practice Address - Street 1:15217 SAN BERNARDINO AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-5327
Practice Address - Country:US
Practice Address - Phone:951-643-2150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1486101022101YA0400X
CAMPSS-PCIHYD175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)