Provider Demographics
NPI:1669850038
Name:WILLIAMS, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
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 1:5370 JOHNSTOWN ALEXANDRIA RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43031-9575
Mailing Address - Country:US
Mailing Address - Phone:740-670-3255
Mailing Address - Fax:
Practice Address - Street 1:5370 JOHNSTOWN ALEXANDRIA RD
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:OH
Practice Address - Zip Code:43031-9575
Practice Address - Country:US
Practice Address - Phone:740-670-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15005225X00000X
IA073233225X00000X
TX116342225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist