=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073818175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIANE W WILLIAMS PSYD PC D/B/A INTEGRATIVE MENTAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2011
-----------------------------------------------------
Last Update Date | 01/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3001 NORTHRIDGE DR STE A
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87401-2084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-327-3145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1864
-----------------------------------------------------
City | AZTEC
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87410-4864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-327-3145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DIANE W WILLIAMS
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 505-327-3145
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1119
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------