Provider Demographics
NPI:1073066411
Name:WILLIAMS, MARCELLA (PTA)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4371 DRY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DIXIE
Mailing Address - State:GA
Mailing Address - Zip Code:31629-3041
Mailing Address - Country:US
Mailing Address - Phone:229-300-6135
Mailing Address - Fax:
Practice Address - Street 1:433 N MCGRIFF ST
Practice Address - Street 2:
Practice Address - City:WHIGHAM
Practice Address - State:GA
Practice Address - Zip Code:39897-2146
Practice Address - Country:US
Practice Address - Phone:229-762-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA295225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant