Provider Demographics
NPI:1689441404
Name:WILLIAMSON, JUSTIN (MA)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 WATERFORD VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8586
Mailing Address - Country:US
Mailing Address - Phone:601-590-0864
Mailing Address - Fax:
Practice Address - Street 1:942 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2582
Practice Address - Country:US
Practice Address - Phone:336-355-8244
Practice Address - Fax:336-546-7630
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19289101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health