Basic Information
| Provider Information | |||||||||
| NPI: | 1356672802 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA, RRT | ||||||||
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| Mailing Information | |||||||||
| Address1: | R.R. 2 BOX 423 | ||||||||
| Address2: | |||||||||
| City: | GRAFTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407091364 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 161 BAKERS RIDGE ROAD | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042850692 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2010 | ||||||||
| LastUpdateDate: | 01/22/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA 001488 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.