Healthcare Provider Details

I. General information

NPI: 1235829292
Provider Name (Legal Business Name): GARY ALLEN WILLIAMS CAC II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 15TH ST SE
WASHINGTON DC
20003-1519
US

IV. Provider business mailing address

5717 CYPRESS CREEK DR APT 303
HYATTSVILLE MD
20782-1830
US

V. Phone/Fax

Practice location:
  • Phone: 202-543-4558
  • Fax: 202-543-4579
Mailing address:
  • Phone: 202-213-1214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1291
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: