Provider Demographics
NPI:1124190327
Name:WILLARD, JEREMY ALAN (PTA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:ALAN
Last Name:WILLARD
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 1:50 WEST PARISHVILLE RD
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676
Mailing Address - Country:US
Mailing Address - Phone:315-268-1915
Mailing Address - Fax:
Practice Address - Street 1:ST. LAWRENCE NTSARC INC
Practice Address - Street 2:63 1-2 B SOUTH MAIN STREET
Practice Address - City:NORWOOD
Practice Address - State:NY
Practice Address - Zip Code:13668
Practice Address - Country:US
Practice Address - Phone:315-353-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0055051225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant