Basic Information
| Provider Information | |||||||||
| NPI: | 1154872109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PT, DPT, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 115 | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851470002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207962600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 483 W SEED FARM RD | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025281200 | ||||||||
| FaxNumber: | 6025281255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2016 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12486 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.