Healthcare Provider Details

I. General information

NPI: 1558296590
Provider Name (Legal Business Name): DIERRE G WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 UNIVERSAL CITY PLZ
UNIVERSAL CITY CA
91608-1002
US

IV. Provider business mailing address

300 45TH ST S
FARGO ND
58103-1189
US

V. Phone/Fax

Practice location:
  • Phone: 833-831-8946
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number5894
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: