Healthcare Provider Details

I. General information

NPI: 1770693582
Provider Name (Legal Business Name): CHARLES M WILLIAMSON PT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 FOREST RDG
PETAL MS
39465-5938
US

IV. Provider business mailing address

48 FOREST RDG
PETAL MS
39465-5938
US

V. Phone/Fax

Practice location:
  • Phone: 601-584-9001
  • Fax:
Mailing address:
  • Phone: 601-584-9001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT0963
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: