Provider Demographics
NPI:1316368210
Name:WILLIAMS, DUSTIN REY (LMP)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:REY
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 E CASINO RD
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-6535
Mailing Address - Country:US
Mailing Address - Phone:425-346-0909
Mailing Address - Fax:
Practice Address - Street 1:2615 W CASINO RD
Practice Address - Street 2:3H
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-2124
Practice Address - Country:US
Practice Address - Phone:425-346-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60175113225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist