Provider Demographics
NPI:1144773011
Name:WILLIAMS, DUSTIN GRANT (PHD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:GRANT
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4709 ARCHER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-6605
Mailing Address - Country:US
Mailing Address - Phone:816-651-1750
Mailing Address - Fax:
Practice Address - Street 1:4709 ARCHER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409-6605
Practice Address - Country:US
Practice Address - Phone:816-651-1750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011009699101YP2500X
NC4927103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional