Healthcare Provider Details

I. General information

NPI: 1952210676
Provider Name (Legal Business Name): KASIAH TARA JUNE WILLIAMSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2661 GG.75 LN
GARDEN MI
49835-9422
US

IV. Provider business mailing address

2661 GG.75 LN
GARDEN MI
49835-9422
US

V. Phone/Fax

Practice location:
  • Phone: 715-923-9172
  • Fax:
Mailing address:
  • Phone: 715-923-9172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5501304711
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: