Provider Demographics
NPI:1154385094
Name:WILLIAMS, VAUGHN (PT)
Entity type:Individual
Prefix:MR
First Name:VAUGHN
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4412
Mailing Address - Country:US
Mailing Address - Phone:770-830-9517
Mailing Address - Fax:770-830-5957
Practice Address - Street 1:812 S PARK ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4412
Practice Address - Country:US
Practice Address - Phone:770-830-9517
Practice Address - Fax:770-830-5957
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00658699CMedicaid