Provider Demographics
NPI:1467158311
Name:WILLIAMS, GAVIN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11070 POTTER RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-9737
Mailing Address - Country:US
Mailing Address - Phone:810-875-8636
Mailing Address - Fax:
Practice Address - Street 1:2138 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-8482
Practice Address - Country:US
Practice Address - Phone:810-412-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501302023225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist