MEDICARE: MR. FREDRICK R WILLIAMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1134493414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FREDRICK R WILLIAMS

Provider Business Mailing Address
First Line	:	5608 MAJESTIC TIDE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-2517
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5608 MAJESTIC TIDE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-2517
Country	:	US
Telephone Number	:	702-533-5621
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2012
Last Update Date	:	03/03/2012

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