Provider Demographics
NPI:1457519373
Name:WILLIAMS, THEODORE L (EDD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-2615
Mailing Address - Country:US
Mailing Address - Phone:605-225-1010
Mailing Address - Fax:605-725-8057
Practice Address - Street 1:628 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-2615
Practice Address - Country:US
Practice Address - Phone:605-225-1010
Practice Address - Fax:605-725-8057
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD302101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional