Provider Demographics
NPI:1578073334
Name:WILLIAMS, KEYON
Entity Type:Individual
Prefix:
First Name:KEYON
Middle Name:
Last Name:WILLIAMS
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 1:7000 RED FOX TRL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-3500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7000 RED FOX TRAIL
Practice Address - Street 2:SHREVEPORT
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129
Practice Address - Country:US
Practice Address - Phone:318-220-8423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health