Provider Demographics
NPI:1821551482
Name:WILLIAMS, CORY
Entity Type:Individual
Prefix:
First Name:CORY
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 1:5295 JOHNS RD
Mailing Address - Street 2:
Mailing Address - City:HUEYTOWN
Mailing Address - State:AL
Mailing Address - Zip Code:35023-5928
Mailing Address - Country:US
Mailing Address - Phone:205-834-1731
Mailing Address - Fax:
Practice Address - Street 1:1501 DECATUR HWY
Practice Address - Street 2:
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-3857
Practice Address - Country:US
Practice Address - Phone:205-834-1731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3838225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL3838Medicaid