Provider Demographics
NPI:1942359831
Name:WILLIAMS, WARDELL TYRONE (LICENSED COUNSELOR)
Entity Type:Individual
Prefix:
First Name:WARDELL
Middle Name:TYRONE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LICENSED COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1639 MAZOR DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-4450
Mailing Address - Country:US
Mailing Address - Phone:706-563-9666
Mailing Address - Fax:706-562-1496
Practice Address - Street 1:3575 MACON RD STE 5
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-8224
Practice Address - Country:US
Practice Address - Phone:706-565-5927
Practice Address - Fax:706-565-8207
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004770101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional