Provider Demographics
NPI:1710782404
Name:WILLIAMS, REVAN SIERRA (PT, DPT)
Entity type:Individual
Prefix:
First Name:REVAN
Middle Name:SIERRA
Last Name:WILLIAMS
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473 WILLOWLAKE DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-5091
Mailing Address - Country:US
Mailing Address - Phone:214-938-0997
Mailing Address - Fax:
Practice Address - Street 1:3930 GLADE RD STE 124
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5932
Practice Address - Country:US
Practice Address - Phone:817-886-3783
Practice Address - Fax:817-438-7776
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1405160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist