Provider Demographics
NPI:1871723064
Name:WILLIAMS, TIMOTHY P (PT, DPT, SCS, CSCS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PT, DPT, SCS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 E MOUNTAIN MAN DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7783
Mailing Address - Country:US
Mailing Address - Phone:307-399-5051
Mailing Address - Fax:
Practice Address - Street 1:1902 E MOUNTAIN MAN DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7783
Practice Address - Country:US
Practice Address - Phone:307-399-5051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist