Provider Demographics
NPI:1912545328
Name:WILLIAMS, LEONDRISS MARCELL JR
Entity Type:Individual
Prefix:
First Name:LEONDRISS
Middle Name:MARCELL
Last Name:WILLIAMS
Suffix:JR
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 1:1440 COLLEGIATE CIR APT 304
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-4669
Mailing Address - Country:US
Mailing Address - Phone:919-633-7018
Mailing Address - Fax:
Practice Address - Street 1:15501 WESTON PKWY STE 130
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-8641
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician