Provider Demographics
NPI:1073534905
Name:SUTCLIFF, WILLIS MARK (MPT, ATC)
Entity Type:Individual
Prefix:
First Name:WILLIS
Middle Name:MARK
Last Name:SUTCLIFF
Suffix:
Gender:M
Credentials:MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5986
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5986
Mailing Address - Country:US
Mailing Address - Phone:714-288-9125
Mailing Address - Fax:714-288-9129
Practice Address - Street 1:255 N TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-7772
Practice Address - Country:US
Practice Address - Phone:714-288-9125
Practice Address - Fax:714-288-9129
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26858225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0268580Medicaid
CAPT0268580Medicaid