Provider Demographics
NPI:1770821639
Name:WILLIAMS, DEIDRE SHAWN (LCAS-A)
Entity Type:Individual
Prefix:MS
First Name:DEIDRE
Middle Name:SHAWN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 HUDSON LANDINGS DR APT H
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0735
Mailing Address - Country:US
Mailing Address - Phone:704-923-4672
Mailing Address - Fax:
Practice Address - Street 1:2224 HUDSON LANDINGS DR APT H
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0735
Practice Address - Country:US
Practice Address - Phone:704-923-4672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-27
Last Update Date:2013-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2293-A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)