Provider Demographics
NPI:1437796836
Name:WILLIAMS, MICHAEL RAY (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
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 1:3319 N UNIVERSITY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4447
Mailing Address - Country:US
Mailing Address - Phone:801-356-0014
Mailing Address - Fax:
Practice Address - Street 1:3319 N UNIVERSITY AVE STE 100
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4447
Practice Address - Country:US
Practice Address - Phone:801-356-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10968926-2501103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling