Provider Demographics
NPI:1083232763
Name:WILLARD, KODIE
Entity Type:Individual
Prefix:
First Name:KODIE
Middle Name:
Last Name:WILLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8865 NORWIN AVE STE 27
Mailing Address - Street 2:
Mailing Address - City:NORTH HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:15642-2769
Mailing Address - Country:US
Mailing Address - Phone:866-287-2036
Mailing Address - Fax:
Practice Address - Street 1:39 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-4914
Practice Address - Country:US
Practice Address - Phone:866-287-2036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician