MEDICARE: REVAN SIERRA WILLIAMS PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1405160	TX

General Provider Information

NPI Number	:	1710782404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REVAN SIERRA WILLIAMS PT, DPT

Provider Business Mailing Address
First Line	:	473 WILLOWLAKE DR
Second Line	:
City	:	LITTLE ELM
State	:	TX
Zip	:	75068-5091
Country	:	US
Telephone Number	:	214-938-0997
Fax Number	:

Provider Business Practice Location Address
First Line	:	3930 GLADE RD STE 124
Second Line	:
City	:	COLLEYVILLE
State	:	TX
Zip	:	76034-5932
Country	:	US
Telephone Number	:	817-886-3783
Fax Number	:	817-438-7776

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2025
Last Update Date	:	02/17/2025

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