Basic Information
| Provider Information | |||||||||
| NPI: | 1245330273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | INGRID | ||||||||
| MiddleName: | STELLA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 W. 21ST STREET | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757692345 | ||||||||
| FaxNumber: | 5757699013 | ||||||||
| Practice Location | |||||||||
| Address1: | 414 MITCHELL ST | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 881017354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057629000 | ||||||||
| FaxNumber: | 5057629009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 03/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0091601 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2610551 | 05 | NM | MEDICAID |