Healthcare Provider Details

I. General information

NPI: 1477036119
Provider Name (Legal Business Name): TYRA WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 HILL STREET
LUFKIN TX
75904
US

IV. Provider business mailing address

1401 N EVENSIDE AVE
HENDERSON TX
75652-5423
US

V. Phone/Fax

Practice location:
  • Phone: 936-637-7215
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: