Provider Demographics
NPI:1467939553
Name:WILLIAMS, DESTIN R
Entity type:Individual
Prefix:
First Name:DESTIN
Middle Name:R
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 1:3609 OCEAN RANCH BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-2700
Mailing Address - Country:US
Mailing Address - Phone:760-418-4611
Mailing Address - Fax:
Practice Address - Street 1:3609 OCEAN RANCH BLVD STE 120
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-2700
Practice Address - Country:US
Practice Address - Phone:760-418-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA15872101YP2500X
CA6593101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health