Provider Demographics
NPI:1023399516
Name:WILLIS, ROBERT WILLIAM (PTA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILLIAM
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 EVERLEA CT
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:MD
Mailing Address - Zip Code:21655-1569
Mailing Address - Country:US
Mailing Address - Phone:210-632-7748
Mailing Address - Fax:
Practice Address - Street 1:14502 GREENVIEW DR
Practice Address - Street 2:SUITE 408
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-3287
Practice Address - Country:US
Practice Address - Phone:301-362-0114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3634225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant