Provider Demographics
NPI:1790132520
Name:WILLIAMS, IVORY
Entity Type:Individual
Prefix:
First Name:IVORY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6017 CANDLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-6305
Mailing Address - Country:US
Mailing Address - Phone:318-272-1501
Mailing Address - Fax:
Practice Address - Street 1:331 MILAM ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-5353
Practice Address - Country:US
Practice Address - Phone:318-213-0904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor