Provider Demographics
NPI:1720796816
Name:WILLIAMS, GAVIN LEVON
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:LEVON
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 1:3197 PIONEER TRAILS LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-3506
Mailing Address - Country:US
Mailing Address - Phone:863-999-3299
Mailing Address - Fax:
Practice Address - Street 1:3197 PIONEER TRAILS LOOP
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-3506
Practice Address - Country:US
Practice Address - Phone:863-999-3299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician