Provider Demographics
NPI:1093865495
Name:MCWILLIAMS, BRIAN JP (MS, LAT, CSCS, CEAS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JP
Last Name:MCWILLIAMS
Suffix:
Gender:M
Credentials:MS, LAT, CSCS, CEAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 SULLIVAN LN
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-3771
Mailing Address - Country:US
Mailing Address - Phone:920-360-4890
Mailing Address - Fax:
Practice Address - Street 1:1002 GEORGE ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-2952
Practice Address - Country:US
Practice Address - Phone:920-360-4890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer