Provider Demographics
NPI:1629074703
Name:WILLIAMS, MICHELE LYN (PT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LYN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MO
Mailing Address - Zip Code:63556-1333
Mailing Address - Country:US
Mailing Address - Phone:660-265-3055
Mailing Address - Fax:660-445-2064
Practice Address - Street 1:203 E 2ND ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MO
Practice Address - Zip Code:63556-1333
Practice Address - Country:US
Practice Address - Phone:660-265-3055
Practice Address - Fax:660-445-2064
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1095225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO144035OtherBLUE CROSS BLUE SHIELD
MO12202900OtherDEPT OF LABOR PN
MO64-00300OtherUNITED HEALTHCARE
MO460774OtherHEALTHLINK
MO7385154OtherAETNA
MO7385154OtherAETNA