Provider Demographics
NPI:1730626276
Name:WILLIAMS, KAITLIN (PTA)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E PUGH DR STE 28
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3938
Mailing Address - Country:US
Mailing Address - Phone:812-232-1776
Mailing Address - Fax:
Practice Address - Street 1:1400 E PUGH DR
Practice Address - Street 2:SUIT 28
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3942
Practice Address - Country:US
Practice Address - Phone:812-232-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005315A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant