Provider Demographics
NPI:1225215916
Name:WILLIAMS, ELAWNTO REGGIE (MBA, PTA, CSCS)
Entity Type:Individual
Prefix:MR
First Name:ELAWNTO
Middle Name:REGGIE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MBA, PTA, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2059 JUNO CIR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-8422
Mailing Address - Country:US
Mailing Address - Phone:850-291-4523
Mailing Address - Fax:
Practice Address - Street 1:4469 MOBILE HWY STE C
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506-7100
Practice Address - Country:US
Practice Address - Phone:850-458-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA19797225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant