Provider Demographics
NPI:1770693582
Name:WILLIAMSON, CHARLES M (PT, ATC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 FOREST RDG
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-5938
Mailing Address - Country:US
Mailing Address - Phone:601-584-9001
Mailing Address - Fax:
Practice Address - Street 1:48 FOREST RDG
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-5938
Practice Address - Country:US
Practice Address - Phone:601-584-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0963225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09170323Medicaid
MS7963405OtherAETNA
MS7963405OtherAETNA
MS7963405OtherAETNA
MS512I650043Medicare PIN