Provider Demographics
NPI:1114155520
Name:WILLIAMS, RADAGAST (LMT)
Entity Type:Individual
Prefix:MR
First Name:RADAGAST
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 140
Mailing Address - Street 2:
Mailing Address - City:HAINES FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12436-0140
Mailing Address - Country:US
Mailing Address - Phone:518-589-0400
Mailing Address - Fax:
Practice Address - Street 1:349 COUNTY ROUTE 25
Practice Address - Street 2:
Practice Address - City:HAINES FALLS
Practice Address - State:NY
Practice Address - Zip Code:12436
Practice Address - Country:US
Practice Address - Phone:518-589-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022746-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY022746-1OtherEDUCATION DEPARTMENT OFFICE OF THE PROFESSIONS