=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366638678
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLBERT BERNARD WILLIAMS SR. M.S.W., L.C.S.W.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2007
-----------------------------------------------------
Last Update Date | 09/20/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2058 E OLDFIELD ST
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93535-1727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-726-7881
-----------------------------------------------------
Fax | 661-940-9317
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44709 DATE AVE
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93534-3101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-726-7881
-----------------------------------------------------
Fax | 661-940-9317
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCS18531
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------