Provider Demographics
NPI:1720264559
Name:WILLIAMS, LABRYON (MA)
Entity Type:Individual
Prefix:
First Name:LABRYON
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 S GLENSTONE AVE
Mailing Address - Street 2:STE E
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1523
Mailing Address - Country:US
Mailing Address - Phone:417-425-9369
Mailing Address - Fax:417-889-0237
Practice Address - Street 1:2117 S STEWART AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2548
Practice Address - Country:US
Practice Address - Phone:417-425-9369
Practice Address - Fax:417-885-0046
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005024470101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health