Healthcare Provider Details

I. General information

NPI: 1144336611
Provider Name (Legal Business Name): WILLIAM ROY BRACKETT MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 E 7TH ST (06/116)
LONG BEACH CA
90822-5201
US

IV. Provider business mailing address

5901 E 7TH ST
LONG BEACH CA
90822-5201
US

V. Phone/Fax

Practice location:
  • Phone: 562-826-8000
  • Fax: 562-826-5969
Mailing address:
  • Phone: 562-826-8473
  • Fax: 562-826-8485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCP00450024
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: