Provider Demographics
NPI:1174823082
Name:WILLIAMS, RENISHA (LMT)
Entity Type:Individual
Prefix:
First Name:RENISHA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2747 W SOUTHERN AVE
Mailing Address - Street 2:STE. 7
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-4249
Mailing Address - Country:US
Mailing Address - Phone:602-437-3772
Mailing Address - Fax:
Practice Address - Street 1:2747 W SOUTHERN AVE
Practice Address - Street 2:STE. 7
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-4249
Practice Address - Country:US
Practice Address - Phone:602-437-3772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-03688P225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist