Provider Demographics
NPI:1750388922
Name:DEAREN, WILLIAM J (PT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:DEAREN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 LAKES BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6813
Mailing Address - Country:US
Mailing Address - Phone:706-802-1991
Mailing Address - Fax:706-802-1408
Practice Address - Street 1:140 LAKES BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6813
Practice Address - Country:US
Practice Address - Phone:706-802-1991
Practice Address - Fax:706-802-1408
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005992225100000X
FLPT17063225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116793Medicare ID - Type UnspecifiedS GA MEDICARE