Provider Demographics
NPI:1003186446
Name:WILLIS, JUSTIN RYAN (LMT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RYAN
Last Name:WILLIS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12409 ALBION ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80241-2932
Mailing Address - Country:US
Mailing Address - Phone:303-525-0573
Mailing Address - Fax:
Practice Address - Street 1:12409 ALBION ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80241-2932
Practice Address - Country:US
Practice Address - Phone:303-525-0573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO224Y00000X
CO2910225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist