Provider Demographics
NPI:1164854303
Name:WILLY, BENJAMIN M (ATC)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:M
Last Name:WILLY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:4150 MAIN ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3445
Practice Address - Country:US
Practice Address - Phone:423-942-8073
Practice Address - Fax:423-942-6660
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20562255A2300X
ARAT 5582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer