Provider Demographics
NPI:1073818175
Name:DIANE W WILLIAMS PSYD PC D/B/A INTEGRATIVE MENTAL HEALTH
Entity Type:Organization
Organization Name:DIANE W WILLIAMS PSYD PC D/B/A INTEGRATIVE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:505-327-3145
Mailing Address - Street 1:PO BOX 1864
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-4864
Mailing Address - Country:US
Mailing Address - Phone:505-327-3145
Mailing Address - Fax:
Practice Address - Street 1:3001 NORTHRIDGE DR STE A
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2084
Practice Address - Country:US
Practice Address - Phone:505-327-3145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1119103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty