Provider Demographics
NPI:1548606593
Name:WILLIAMS LIFE CENTER
Entity Type:Organization
Organization Name:WILLIAMS LIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLEVELAND
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-345-0821
Mailing Address - Street 1:6301 IVY LN
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-1402
Mailing Address - Country:US
Mailing Address - Phone:301-345-0821
Mailing Address - Fax:301-345-0828
Practice Address - Street 1:6301 IVY LN
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-1402
Practice Address - Country:US
Practice Address - Phone:301-345-0821
Practice Address - Fax:301-345-0828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD142041041C0700X
MD177851041C0700X
MD161611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD8085013Medicaid