Provider Demographics
NPI:1215356332
Name:WILLIAMS, EDDIE LEE IV
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:LEE
Last Name:WILLIAMS
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1838 EASTMAN AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6496
Mailing Address - Country:US
Mailing Address - Phone:805-289-0120
Mailing Address - Fax:
Practice Address - Street 1:1838 EASTMAN AVE
Practice Address - Street 2:UNIT 100
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6496
Practice Address - Country:US
Practice Address - Phone:805-289-0120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA56CCOtherASPIRA