Provider Demographics
NPI:1528584026
Name:WILLIAMS, AMANTHIA PEACE (PEDORTHIST)
Entity Type:Individual
Prefix:MS
First Name:AMANTHIA
Middle Name:PEACE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PEDORTHIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3645 CALDER AVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-5027
Mailing Address - Country:US
Mailing Address - Phone:409-833-0053
Mailing Address - Fax:409-833-0671
Practice Address - Street 1:3645 CALDER AVE.
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706
Practice Address - Country:US
Practice Address - Phone:409-833-0053
Practice Address - Fax:409-833-0671
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3-20480-8839-0OtherCOMPTROLLER OF PUBLIC ACCOUNTS
TX45-5405320Medicaid