Provider Demographics
NPI:1912506544
Name:WILLIAMS, PHILLIP GEORGE
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:GEORGE
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 1:271B CULVER ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4855
Mailing Address - Country:US
Mailing Address - Phone:678-883-8609
Mailing Address - Fax:678-559-0409
Practice Address - Street 1:271B CULVER ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4855
Practice Address - Country:US
Practice Address - Phone:678-883-8609
Practice Address - Fax:678-559-0409
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-24
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAEINOtherEINS