Provider Demographics
NPI:1447778469
Name:WILLIAMS, GWENIQUE
Entity Type:Individual
Prefix:
First Name:GWENIQUE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 N MAPLE DR UNIT 2076
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90213-4769
Mailing Address - Country:US
Mailing Address - Phone:323-475-7407
Mailing Address - Fax:323-475-7407
Practice Address - Street 1:13768 MEADOW VIEW LN
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-7006
Practice Address - Country:US
Practice Address - Phone:323-475-7407
Practice Address - Fax:323-475-7407
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician