Provider Demographics
NPI:1972017770
Name:WILLIAMS, QUANTRAVIUS EARL
Entity type:Individual
Prefix:
First Name:QUANTRAVIUS
Middle Name:EARL
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 1:733 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-3919
Mailing Address - Country:US
Mailing Address - Phone:904-377-4990
Mailing Address - Fax:
Practice Address - Street 1:2101 ARC DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-0512
Practice Address - Country:US
Practice Address - Phone:904-824-7249
Practice Address - Fax:904-824-7249
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst