Provider Demographics
NPI:1366822421
Name:WILLIAMSON, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:WILLIAMSON
Suffix:
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 1:4527 AMANDAS CV
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-3536
Mailing Address - Country:US
Mailing Address - Phone:210-464-6518
Mailing Address - Fax:
Practice Address - Street 1:602 E. AFTON OAKS BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244
Practice Address - Country:US
Practice Address - Phone:210-662-0727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70240101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional