Provider Demographics
NPI:1639556152
Name:WILLIAMS, LARRY (CAS)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5331 VIRTUE ARC DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6033
Mailing Address - Country:US
Mailing Address - Phone:510-247-8300
Mailing Address - Fax:510-247-8295
Practice Address - Street 1:795 FLETCHER LN
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-1008
Practice Address - Country:US
Practice Address - Phone:510-247-8300
Practice Address - Fax:510-247-8295
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC13781214171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator