Provider Demographics
NPI:1992117121
Name:WILLIAMS, SHAQUANA (PTA)
Entity type:Individual
Prefix:
First Name:SHAQUANA
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 1:1000 SAINT LOUIS AVE
Mailing Address - Street 2:SUITE102
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3366
Mailing Address - Country:US
Mailing Address - Phone:817-921-5020
Mailing Address - Fax:817-921-5022
Practice Address - Street 1:305 NE LOOP 280; BUSINESS TOWER 1
Practice Address - Street 2:SUITE 200
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053
Practice Address - Country:US
Practice Address - Phone:817-292-8787
Practice Address - Fax:817-789-6849
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4052121225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant