Provider Demographics
NPI:1013271055
Name:WILLIAMS, GAVIN JOHN
Entity Type:Individual
Prefix:MR
First Name:GAVIN
Middle Name:JOHN
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 1:1026 FLORIN RD # 289
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3513
Mailing Address - Country:US
Mailing Address - Phone:916-995-2963
Mailing Address - Fax:916-848-0517
Practice Address - Street 1:1700 EUREKA RD STE 155
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7786
Practice Address - Country:US
Practice Address - Phone:916-995-2963
Practice Address - Fax:916-848-0517
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67144106H00000X
CA105126106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist