Provider Demographics
NPI:1952383762
Name:WILLIAMS, MARK TIMOTHY (LISW,LCSW,LADAC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:TIMOTHY
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LISW,LCSW,LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 SAN YSIDRO RD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-5323
Mailing Address - Country:US
Mailing Address - Phone:575-522-2990
Mailing Address - Fax:
Practice Address - Street 1:3118 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4915
Practice Address - Country:US
Practice Address - Phone:575-649-3076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-062231041C0700X
NM0110541101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)