Provider Demographics
NPI:1609298389
Name:WILLIAMS, AUDREY (DPT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 JAMIE AVE
Mailing Address - Street 2:APT B
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:ENERGY
Practice Address - State:IL
Practice Address - Zip Code:62933-3568
Practice Address - Country:US
Practice Address - Phone:618-942-7014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020191225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist