Healthcare Provider Details

I. General information

NPI: 1285568808
Provider Name (Legal Business Name): COY ORVILLE WILLIARD III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 N MARIPOSA AVE
LOS ANGELES CA
90004-4509
US

IV. Provider business mailing address

13181 CROSSROADS PKWY N STE 440
CITY OF INDUSTRY CA
91746-3499
US

V. Phone/Fax

Practice location:
  • Phone: 213-736-5441
  • Fax:
Mailing address:
  • Phone: 562-353-5611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRT1421941025
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: