Healthcare Provider Details

I. General information

NPI: 1245855071
Provider Name (Legal Business Name): AMBER WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14677 MERRILL AVE
FONTANA CA
92335-4219
US

IV. Provider business mailing address

2947 MUIR MOUNTAIN WAY
SAN BERNARDINO CA
92407-5185
US

V. Phone/Fax

Practice location:
  • Phone: 951-643-2340
  • Fax:
Mailing address:
  • Phone: 714-860-0247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number41686
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: