Provider Demographics
NPI:1255465803
Name:WILLIAMS, DOUGLAS CARLTON (MS, LP & LMFT)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:CARLTON
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MS, LP & LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 FREMONT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-1122
Mailing Address - Country:US
Mailing Address - Phone:612-823-3707
Mailing Address - Fax:612-822-1360
Practice Address - Street 1:1516 W LAKE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2554
Practice Address - Country:US
Practice Address - Phone:612-823-3707
Practice Address - Fax:612-822-1360
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0994103TF0000X, 103TF0200X
MNLO0994103TP2701X
MN179106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6253218OtherUBH
66G32WIOtherBCBS