Provider Demographics
NPI:1679655922
Name:WILLIAMS, ROGER ALAN (PHD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:ALAN
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 1:1550 COLLEGE ST
Mailing Address - Street 2:A
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31207-0001
Mailing Address - Country:US
Mailing Address - Phone:478-301-5930
Mailing Address - Fax:478-301-5932
Practice Address - Street 1:655 FIRST STREET
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-301-5930
Practice Address - Fax:478-301-5932
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001108103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA680006605OtherRAILROAD MEDICARE
GA000342933AMedicaid
R64767Medicare UPIN
GA680006605OtherRAILROAD MEDICARE