MEDICARE: CHARLES WESLEY WILLIAMS CDCA II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDCA.178150	OH

General Provider Information

NPI Number	:	1396509519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES WESLEY WILLIAMS CDCA II

Provider Business Mailing Address
First Line	:	15825 LAKE SHORE BLVD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110-1052
Country	:	US
Telephone Number	:	216-526-8346
Fax Number	:	800-856-4265

Provider Business Practice Location Address
First Line	:	15825 LAKE SHORE BLVD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110-1052
Country	:	US
Telephone Number	:	216-526-8346
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2024
Last Update Date	:	02/08/2024

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