Provider Demographics
NPI:1700185675
Name:WILLIAMSON, MARY B
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 WAPPATO CT
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-9360
Mailing Address - Country:US
Mailing Address - Phone:406-624-6897
Mailing Address - Fax:
Practice Address - Street 1:3524 WAPPATO CT
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-9360
Practice Address - Country:US
Practice Address - Phone:406-624-6897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2155225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant