Provider Demographics
NPI:1346234671
Name:WILLIAMS, TRACI R (PT)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:R
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12241 INDUSTRIAL BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8301
Mailing Address - Country:US
Mailing Address - Phone:800-489-6905
Mailing Address - Fax:626-294-0080
Practice Address - Street 1:12241 INDUSTRIAL BLVD STE 210
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8301
Practice Address - Country:US
Practice Address - Phone:800-489-6905
Practice Address - Fax:626-294-0080
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22968225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11470070OtherCAQH
W1791415OtherHIGHMARK