Provider Demographics
NPI:1558934661
Name:WILLIAMS, WILBERT T
Entity Type:Individual
Prefix:
First Name:WILBERT
Middle Name:T
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 YORKSHIRE BLVD APT 210
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3514
Mailing Address - Country:US
Mailing Address - Phone:313-465-0618
Mailing Address - Fax:
Practice Address - Street 1:29433 SOUTHFIELD RD
Practice Address - Street 2:SUITE 208 ROOM 8
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076
Practice Address - Country:US
Practice Address - Phone:313-768-6994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist