Provider Demographics
NPI:1568408730
Name:WILLIAMS, DALE WAYNE (PHD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:WAYNE
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 1:2704 BENBROOK DRIVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-6953
Mailing Address - Country:US
Mailing Address - Phone:512-576-8656
Mailing Address - Fax:512-459-2101
Practice Address - Street 1:8705 SHOAL CREEK BLVD
Practice Address - Street 2:STE. 108
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-6802
Practice Address - Country:US
Practice Address - Phone:512-576-8656
Practice Address - Fax:512-459-2101
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21580103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000T97A2Medicaid
S17353Medicare UPIN
00T97AMedicare ID - Type Unspecified