Provider Demographics
NPI:1609377852
Name:WILLIAMS, DIEDRE SUZANNE
Entity Type:Individual
Prefix:
First Name:DIEDRE
Middle Name:SUZANNE
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 1:5145 EL CAMINO AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-5071
Mailing Address - Country:US
Mailing Address - Phone:916-613-3977
Mailing Address - Fax:
Practice Address - Street 1:1050 FULTON AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4272
Practice Address - Country:US
Practice Address - Phone:916-974-2599
Practice Address - Fax:916-444-8901
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician