Provider Demographics
NPI:1124196407
Name:WILLSON, THOMAS C IV (PT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:C
Last Name:WILLSON
Suffix:IV
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 1:6 PUCHALA DR
Mailing Address - Street 2:
Mailing Address - City:PARLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08859-2179
Mailing Address - Country:US
Mailing Address - Phone:914-527-0881
Mailing Address - Fax:877-557-2965
Practice Address - Street 1:6 PUCHALA DR
Practice Address - Street 2:
Practice Address - City:PARLIN
Practice Address - State:NJ
Practice Address - Zip Code:08859-2179
Practice Address - Country:US
Practice Address - Phone:914-527-0881
Practice Address - Fax:877-557-2965
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023194225100000X
NJ40QA00969800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist