Provider Demographics
NPI:1144222845
Name:WILLIAMS, WANDA TERESA (MS, LCAS)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:TERESA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MS, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 N QUEEN ST
Mailing Address - Street 2:SUITE110
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-4984
Mailing Address - Country:US
Mailing Address - Phone:252-522-8002
Mailing Address - Fax:252-523-1685
Practice Address - Street 1:327 N QUEEN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-4984
Practice Address - Country:US
Practice Address - Phone:252-522-8002
Practice Address - Fax:252-523-1685
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NC6111762101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111762Medicaid
NC169VROtherBCBS