1750445557 NPI number — EDMOND DESHAWN WILLIAMS MSW, QMHP

Table of content: EDMOND DESHAWN WILLIAMS MSW, QMHP (NPI 1750445557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750445557 NPI number — EDMOND DESHAWN WILLIAMS MSW, QMHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
EDMOND
Provider Middle Name:
DESHAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, QMHP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLIAMS
Provider Other First Name:
EDMOND
Provider Other Middle Name:
DESHAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1750445557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 16932
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97292-0932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-334-9955
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
421 SW OAK ST
Provider Second Line Business Practice Location Address:
SUITE 520
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97204-1817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-312-2116
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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