Healthcare Provider Details

I. General information

NPI: 1528575578
Provider Name (Legal Business Name): MARTIN WILLIAMS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 E GARRISON BLVD STE A
GASTONIA NC
28054-5143
US

IV. Provider business mailing address

2420 CELANESE RD APT 212
ROCK HILL SC
29732-0025
US

V. Phone/Fax

Practice location:
  • Phone: 980-430-9205
  • Fax: 704-799-8949
Mailing address:
  • Phone: 803-402-1459
  • Fax: 704-799-8949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA17916
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA17916
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: