Provider Demographics
NPI:1356672802
Name:WILLIAMS, JUSTIN M (PTA, RRT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:M
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PTA, RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:R.R. 2 BOX 423
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354
Mailing Address - Country:US
Mailing Address - Phone:740-709-1364
Mailing Address - Fax:
Practice Address - Street 1:161 BAKERS RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508
Practice Address - Country:US
Practice Address - Phone:304-285-0692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA 001488225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant