Provider Demographics
NPI:1710468590
Name:WILLIAMS FORDE, TRISH VANESSA
Entity Type:Individual
Prefix:
First Name:TRISH
Middle Name:VANESSA
Last Name:WILLIAMS FORDE
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 1:3415 S SEPULVEDA BLVD STE 1100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-7090
Mailing Address - Country:US
Mailing Address - Phone:310-881-2700
Mailing Address - Fax:
Practice Address - Street 1:3415 S SEPULVEDA BLVD STE 1100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-7090
Practice Address - Country:US
Practice Address - Phone:310-881-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2021-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA829012163WC0400X
CA95019273363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management