Provider Demographics
NPI:1952865719
Name:WILLIAMS, WANDA JEAN (RADT)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:JEAN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 EXPOSITION BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-4250
Mailing Address - Country:US
Mailing Address - Phone:323-826-0070
Mailing Address - Fax:
Practice Address - Street 1:717 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2845
Practice Address - Country:US
Practice Address - Phone:310-399-9883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)