Provider Demographics
NPI:1790397347
Name:WILLIAMS, KEVIN (DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 GOLDEN GATE CT NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-5307
Mailing Address - Country:US
Mailing Address - Phone:505-620-9430
Mailing Address - Fax:
Practice Address - Street 1:7424 HOLLY AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2554
Practice Address - Country:US
Practice Address - Phone:505-797-5505
Practice Address - Fax:505-797-5510
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist