Provider Demographics
NPI:1760737928
Name:WILLIAMS, BLAIN MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:BLAIN
Middle Name:MICHAEL
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 ROMBACH AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-1946
Mailing Address - Country:US
Mailing Address - Phone:937-283-2186
Mailing Address - Fax:937-283-2187
Practice Address - Street 1:1475 ROMBACH AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-1946
Practice Address - Country:US
Practice Address - Phone:937-283-2186
Practice Address - Fax:937-283-2187
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT013777225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist