MEDICARE: MR. ELAWNTO REGGIE WILLIAMS MBA, PTA, CSCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA19797	FL

General Provider Information

NPI Number	:	1225215916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ELAWNTO REGGIE WILLIAMS MBA, PTA, CSCS

Provider Business Mailing Address
First Line	:	2059 JUNO CIR
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32526-8422
Country	:	US
Telephone Number	:	850-291-4523
Fax Number	:

Provider Business Practice Location Address
First Line	:	4469 MOBILE HWY STE C
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32506-7100
Country	:	US
Telephone Number	:	850-458-2020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2008
Last Update Date	:	07/21/2022

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