Provider Demographics
NPI:1851916597
Name:WILLIAMS, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
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 1:3065 GOODWIN SCHOOLHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:OH
Mailing Address - Zip Code:45106-8452
Mailing Address - Country:US
Mailing Address - Phone:513-602-8484
Mailing Address - Fax:
Practice Address - Street 1:5535 S WILLIAMSON BLVD STE 774
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-8321
Practice Address - Country:US
Practice Address - Phone:888-265-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28343235Z00000X
MI7101006816235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist