Healthcare Provider Details

I. General information

NPI: 1538772280
Provider Name (Legal Business Name): THERON ULYSSES WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date: 05/21/2024
Reactivation Date: 06/13/2024

III. Provider practice location address

630 HAINES AVE NW
ALBUQUERQUE NM
87102-1226
US

IV. Provider business mailing address

630 HAINES AVE NW
ALBUQUERQUE NM
87102-1226
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-5611
  • Fax: 505-268-5736
Mailing address:
  • Phone: 505-268-5611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2024-0336
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: