Provider Demographics
NPI:1457418501
Name:WILLIAMS, GARY DAVID
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DAVID
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 1:4650 PARKHILL RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:93453-9650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2178 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4535
Practice Address - Country:US
Practice Address - Phone:805-781-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29244167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician