Healthcare Provider Details

I. General information

NPI: 1881901593
Provider Name (Legal Business Name): RYAN CASEY WILLIAMSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2010
Last Update Date: 09/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 W HAY ST SUITE 218
DECATUR IL
62526-6328
US

IV. Provider business mailing address

304 W HAY ST SUITE 218
DECATUR IL
62526-6328
US

V. Phone/Fax

Practice location:
  • Phone: 217-877-2088
  • Fax: 217-877-3622
Mailing address:
  • Phone: 217-877-2088
  • Fax: 217-877-3622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.002425
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: