Provider Demographics
NPI:1902335078
Name:WILLIAMS, DEANNA L
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:F
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 191456
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-9456
Mailing Address - Country:US
Mailing Address - Phone:404-750-5623
Mailing Address - Fax:
Practice Address - Street 1:3757 SANTA ROSALIA DRIVE
Practice Address - Street 2:#628
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008
Practice Address - Country:US
Practice Address - Phone:404-750-5623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954505783Medicaid