Provider Demographics
NPI:1770794141
Name:WILLIAMS, DIANE
Entity type:Individual
Prefix:MISS
First Name:DIANE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 EL PORTEL DRIVE
Mailing Address - Street 2:106
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806
Mailing Address - Country:US
Mailing Address - Phone:510-374-7006
Mailing Address - Fax:510-374-3328
Practice Address - Street 1:2523 EL PORTAL DR
Practice Address - Street 2:106
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3305
Practice Address - Country:US
Practice Address - Phone:510-374-7006
Practice Address - Fax:510-374-3328
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARAS,CAARR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)