Provider Demographics
NPI:1790947737
Name:WILLIAMS, THEODORA VAUGHN (CDCI)
Entity Type:Individual
Prefix:
First Name:THEODORA
Middle Name:VAUGHN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CDCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 1731
Mailing Address - Street 2:219 GREIF ST
Mailing Address - City:WRANGELL
Mailing Address - State:AK
Mailing Address - Zip Code:99929
Mailing Address - Country:US
Mailing Address - Phone:907-305-3055
Mailing Address - Fax:907-874-2576
Practice Address - Street 1:333 CHURCH ST
Practice Address - Street 2:
Practice Address - City:WRANGELL
Practice Address - State:AK
Practice Address - Zip Code:99929
Practice Address - Country:US
Practice Address - Phone:907-305-3055
Practice Address - Fax:907-874-2576
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2673101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)