=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285568808
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COY ORVILLE WILLIARD III
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2026
-----------------------------------------------------
Last Update Date | 06/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 N MARIPOSA AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90004-4509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-736-5441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13181 CROSSROADS PKWY N STE 440
-----------------------------------------------------
City | CITY OF INDUSTRY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91746-3499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-353-5611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | RT1421941025
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------