Provider Demographics
NPI:1467596809
Name:WILLIAMS, KEVIN JOSEPH (MS, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOSEPH
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CLOVERLEAF CIR
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:WV
Mailing Address - Zip Code:25306-6542
Mailing Address - Country:US
Mailing Address - Phone:304-925-7605
Mailing Address - Fax:
Practice Address - Street 1:200 TRACY WAY
Practice Address - Street 2:NORTHGATE BUSINESS PARK
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1258
Practice Address - Country:US
Practice Address - Phone:304-388-4900
Practice Address - Fax:304-388-4910
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer