=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417302605
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHEAL WILLIAMS JR. MA, CCC-SLP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2016
-----------------------------------------------------
Last Update Date | 01/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15928 VENTURA BLVD STE 218
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-4413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-518-9709
-----------------------------------------------------
Fax | 747-230-8320
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15928 VENTURA BLVD STE 218
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-4413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-518-9709
-----------------------------------------------------
Fax | 747-230-8320
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP 21091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------