Provider Demographics
NPI:1003690751
Name:MEADOWS, WILLIE R (SUD COUNSELOR)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:R
Last Name:MEADOWS
Suffix:
Gender:M
Credentials:SUD COUNSELOR
Other - Prefix:
Other - First Name:WILLIE
Other - Middle Name:R
Other - Last Name:MEADOWS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SUD COUNSELOR
Mailing Address - Street 1:4660 EL CAJON BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-4466
Mailing Address - Country:US
Mailing Address - Phone:619-597-7335
Mailing Address - Fax:619-642-2735
Practice Address - Street 1:4660 EL CAJON BLVD STE 210
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-4466
Practice Address - Country:US
Practice Address - Phone:619-597-7335
Practice Address - Fax:619-642-2735
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15171101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)