Healthcare Provider Details

I. General information

NPI: 1629423462
Provider Name (Legal Business Name): LORI WILLIAMS CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 PALM AVE
RIVERSIDE CA
92501-4012
US

IV. Provider business mailing address

23950 PRADO LN
COLTON CA
92324-9734
US

V. Phone/Fax

Practice location:
  • Phone: 909-608-2002
  • Fax:
Mailing address:
  • Phone: 909-514-1958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI07270317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: