Provider Demographics
NPI:1629541750
Name:WILLIAMS, MARK ROBERT (LMT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ROBERT
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 SPRING RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10992-1830
Mailing Address - Country:US
Mailing Address - Phone:201-390-2325
Mailing Address - Fax:
Practice Address - Street 1:175 ROCK RD
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-1747
Practice Address - Country:US
Practice Address - Phone:201-390-2325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018369-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist