Provider Demographics
NPI:1053627760
Name:WILLIAMS, BRANDON SCOTT (MA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:SCOTT
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 W EAGLES NEST DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70611-4353
Mailing Address - Country:US
Mailing Address - Phone:719-320-5693
Mailing Address - Fax:
Practice Address - Street 1:1312 W EAGLES NEST DR
Practice Address - Street 2:
Practice Address - City:MOSS BLUFF
Practice Address - State:LA
Practice Address - Zip Code:70611-4353
Practice Address - Country:US
Practice Address - Phone:719-320-5693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LA5718101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health