Healthcare Provider Details

I. General information

NPI: 1407340060
Provider Name (Legal Business Name): TERRENCE WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7416 N MAIN ST STE E
DAYTON OH
45415-2559
US

IV. Provider business mailing address

5224 BELLE ISLE DR
DAYTON OH
45439-3236
US

V. Phone/Fax

Practice location:
  • Phone: 937-270-4945
  • Fax:
Mailing address:
  • Phone: 937-270-4945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC161873
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS1200858
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: