Provider Demographics
NPI:1053737981
Name:WILLIAMS, BROCKMAN CHASE (LPTA)
Entity type:Individual
Prefix:
First Name:BROCKMAN
Middle Name:CHASE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11562 OLD HWY 61 N
Mailing Address - Street 2:APT 19-2
Mailing Address - City:ROBINSONVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38664
Mailing Address - Country:US
Mailing Address - Phone:662-251-5081
Mailing Address - Fax:
Practice Address - Street 1:711 AVIGNON DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5120
Practice Address - Country:US
Practice Address - Phone:601-605-6777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA5338174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist