Provider Demographics
NPI:1164750816
Name:WILLIAMS, TINA ANNETTE
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:ANNETTE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:ANNETTE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:495 E ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-2744
Mailing Address - Country:US
Mailing Address - Phone:760-353-6151
Mailing Address - Fax:760-353-6152
Practice Address - Street 1:495 E ORANGE AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2744
Practice Address - Country:US
Practice Address - Phone:760-353-6151
Practice Address - Fax:760-353-6152
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XMedicaid