Provider Demographics
NPI:1144045071
Name:WILLIAMS, DEMONTE (PRSS,CHW)
Entity type:Individual
Prefix:
First Name:DEMONTE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PRSS,CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12309 W CAMBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-5575
Mailing Address - Country:US
Mailing Address - Phone:251-477-5676
Mailing Address - Fax:
Practice Address - Street 1:2655 W GUADALUPE RD UNIT SUITE7
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-7259
Practice Address - Country:US
Practice Address - Phone:314-494-7603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-16
Last Update Date:2024-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 251B00000X, 251S00000X
AZCHW0000000323172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health