Provider Demographics
NPI:1205617230
Name:WILLIAMS, MICHAEL DEVANTE (LGPC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEVANTE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1872 SCAFFOLD WAY
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-2932
Mailing Address - Country:US
Mailing Address - Phone:253-686-4884
Mailing Address - Fax:
Practice Address - Street 1:1872 SCAFFOLD WAY
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-2932
Practice Address - Country:US
Practice Address - Phone:253-686-4884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP14428101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health