Healthcare Provider Details

I. General information

NPI: 1306500426
Provider Name (Legal Business Name): TIERA WILLIAMS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 N 400 E STE B
NORTH LOGAN UT
84341-1799
US

IV. Provider business mailing address

724 N 100 W
TREMONTON UT
84337-1003
US

V. Phone/Fax

Practice location:
  • Phone: 435-787-9030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9062733-2402
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: