Provider Demographics
NPI:1538772280
Name:WILLIAMS, THERON ULYSSES
Entity type:Individual
Prefix:
First Name:THERON
Middle Name:ULYSSES
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 HAINES AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1226
Mailing Address - Country:US
Mailing Address - Phone:505-268-5611
Mailing Address - Fax:
Practice Address - Street 1:630 HAINES AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1226
Practice Address - Country:US
Practice Address - Phone:505-268-5611
Practice Address - Fax:505-268-5736
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2024-06-14
Deactivation Date:2024-05-21
Deactivation Code:
Reactivation Date:2024-06-13
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2024-0336101YA0400X
UT171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator