Provider Demographics
NPI:1174863260
Name:WILLIAMS, GORDON RIAN (ATC)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:RIAN
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 HEMLOCK DR
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1029
Mailing Address - Country:US
Mailing Address - Phone:216-650-5480
Mailing Address - Fax:440-824-5769
Practice Address - Street 1:76 LOU GROZA BLVD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-1238
Practice Address - Country:US
Practice Address - Phone:440-891-5128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0033372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer