Provider Demographics
NPI:1164569521
Name:WILLEMS, BERTHA GABRIELA (DR PT)
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:GABRIELA
Last Name:WILLEMS
Suffix:
Gender:F
Credentials:DR PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:101 CLINTON AVE APT 3J
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-2854
Mailing Address - Country:US
Mailing Address - Phone:516-726-0879
Mailing Address - Fax:
Practice Address - Street 1:175 W MERRICK RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3712
Practice Address - Country:US
Practice Address - Phone:516-379-7550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027666-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist