Provider Demographics
NPI:1740617331
Name:WILLIAMS, ROBERT JOHN (MA, LADC, LPC, LAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MA, LADC, LPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 23RD ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2951
Mailing Address - Country:US
Mailing Address - Phone:701-293-0736
Mailing Address - Fax:
Practice Address - Street 1:115 WILLOW ST W
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3922
Practice Address - Country:US
Practice Address - Phone:218-844-5191
Practice Address - Fax:218-844-5193
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302910101YA0400X
ND1685101YA0400X
MN1100101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional