Provider Demographics
NPI:1073614285
Name:WILLIS, ADAM M (PT)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:M
Last Name:WILLIS
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 1:221 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12803-5118
Mailing Address - Country:US
Mailing Address - Phone:518-225-5049
Mailing Address - Fax:
Practice Address - Street 1:206 GLEN ST
Practice Address - Street 2:SUITE #52
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3584
Practice Address - Country:US
Practice Address - Phone:518-538-8778
Practice Address - Fax:518-636-3204
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204833225100000X
WAPT00010625225100000X
NY027046-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0223203OtherDEPARTMENT OF L&I
WA6393WIOtherREGENCE/BLUE SHIELD
WA8944992OtherL&I CRIME VICTIMS
WA92527059OtherAETNA
WA2639WIOtherREGENCE/BLUE SHIELD
WA2149WIOtherREGENCE/BLUESHIELD
VA2305204833OtherLICENSE NUMBER
WA8944992OtherL&I CRIME VICTIMS