Provider Demographics
NPI:1033357264
Name:WILLIS, RANDALL (LOT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:LOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 N EXPRESSWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-6831
Mailing Address - Country:US
Mailing Address - Phone:956-544-7722
Mailing Address - Fax:956-544-7728
Practice Address - Street 1:835 N EXPRESSWAY
Practice Address - Street 2:SUITE A
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-6831
Practice Address - Country:US
Practice Address - Phone:956-544-7722
Practice Address - Fax:956-544-7728
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102642225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169033101Medicaid
TX45-4849OtherMEDICARE