Healthcare Provider Details

I. General information

NPI: 1427701366
Provider Name (Legal Business Name): GARY LEWALL WILLIAMS PEER RECOVERY COACH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15217 SAN BERNARDINO AVE
FONTANA CA
92335-5327
US

IV. Provider business mailing address

15217 SAN BERNARDINO AVE
FONTANA CA
92335-5327
US

V. Phone/Fax

Practice location:
  • Phone: 951-643-2150
  • Fax:
Mailing address:
  • Phone: 951-643-2150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1486101022
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-PCIHYD
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: