Provider Demographics
NPI:1174716005
Name:WILLIAMS, KEITH LEE (PHD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:LEE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3771 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5005
Mailing Address - Country:US
Mailing Address - Phone:208-939-9917
Mailing Address - Fax:888-505-3331
Practice Address - Street 1:3771 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5005
Practice Address - Country:US
Practice Address - Phone:208-939-9917
Practice Address - Fax:888-505-3331
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202563103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical