Healthcare Provider Details

I. General information

NPI: 1619505435
Provider Name (Legal Business Name): BRIAN J WILLEMS CI35270322
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 M ST
FRESNO CA
93721-1808
US

IV. Provider business mailing address

1300 W OLSON AVE SPC 102
REEDLEY CA
93654-3658
US

V. Phone/Fax

Practice location:
  • Phone: 559-264-2700
  • Fax:
Mailing address:
  • Phone: 949-294-8852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRR1372341219
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI35270322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: