Provider Demographics
NPI:1023556586
Name:WILLIAMS, MARLON
Entity Type:Individual
Prefix:
First Name:MARLON
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 W HAWTHORNE TRACE RD
Mailing Address - Street 2:APT 207
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1055
Mailing Address - Country:US
Mailing Address - Phone:414-687-2650
Mailing Address - Fax:
Practice Address - Street 1:2626 N 76TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-1137
Practice Address - Country:US
Practice Address - Phone:414-774-7794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-05
Last Update Date:2017-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1749-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant