Provider Demographics
NPI:1457885485
Name:WILLIAMS, WILFRED LARRY
Entity Type:Individual
Prefix:
First Name:WILFRED
Middle Name:LARRY
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 1:1272 BLUE LAKES RD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-1764
Mailing Address - Country:US
Mailing Address - Phone:775-772-2444
Mailing Address - Fax:
Practice Address - Street 1:1272 BLUE LAKES RD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-1764
Practice Address - Country:US
Practice Address - Phone:775-772-2444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLBA0085103K00000X
1-04-1654103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst