Provider Demographics
NPI:1790489763
Name:WILLIAMS, WESLEY WAYNE SR
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:WAYNE
Last Name:WILLIAMS
Suffix:SR
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:PO BOX 2622
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92393-2622
Mailing Address - Country:US
Mailing Address - Phone:909-695-7410
Mailing Address - Fax:
Practice Address - Street 1:15409 ANACAPA RD STE 409-F
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2463
Practice Address - Country:US
Practice Address - Phone:909-695-7410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1126471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical