Provider Demographics
NPI:1124144704
Name:WILLIAMS, PHYLLIS ANNETTE
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:ANNETTE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3526 CHILDRESS TER
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-2017
Mailing Address - Country:US
Mailing Address - Phone:301-562-1116
Mailing Address - Fax:301-562-1317
Practice Address - Street 1:1105 SPRING ST
Practice Address - Street 2:STE H
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-4026
Practice Address - Country:US
Practice Address - Phone:301-562-1116
Practice Address - Fax:301-562-1317
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18677225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD77600100Medicaid
MD77600100Medicaid