Provider Demographics
NPI:1275836215
Name:WILLIAMS, AUDREY CLARK (MPT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:CLARK
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13540 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-3826
Mailing Address - Country:US
Mailing Address - Phone:818-990-0267
Mailing Address - Fax:818-990-0261
Practice Address - Street 1:13540 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-3826
Practice Address - Country:US
Practice Address - Phone:818-990-0267
Practice Address - Fax:818-990-0261
Is Sole Proprietor?:No
Enumeration Date:2010-12-14
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist