Healthcare Provider Details

I. General information

NPI: 1174863682
Provider Name (Legal Business Name): STANLEY ALLEN WILLIAMS LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 PACIFIC ST STE B
ST AUGUSTINE FL
32084-2784
US

IV. Provider business mailing address

1308 BRENTWOOD CT
ST AUGUSTINE FL
32086-3241
US

V. Phone/Fax

Practice location:
  • Phone: 904-315-1586
  • Fax:
Mailing address:
  • Phone: 904-315-1586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT2667
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: