Provider Demographics
NPI:1619505435
Name:WILLEMS, BRIAN J (CI35270322)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:J
Last Name:WILLEMS
Suffix:
Gender:M
Credentials:CI35270322
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W OLSON AVE SPC 102
Mailing Address - Street 2:
Mailing Address - City:REEDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93654-3658
Mailing Address - Country:US
Mailing Address - Phone:949-294-8852
Mailing Address - Fax:
Practice Address - Street 1:1310 M ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1808
Practice Address - Country:US
Practice Address - Phone:559-264-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-28
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARR1372341219101YA0400X
CACI35270322101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)