Provider Demographics
NPI:1225042435
Name:WILLETT, MICHAEL J (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:WILLETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3633 COUNTRY CLUB BLVD # 1
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-4964
Mailing Address - Country:US
Mailing Address - Phone:239-541-3450
Mailing Address - Fax:239-593-1195
Practice Address - Street 1:9051 TAMIAMI TRL N
Practice Address - Street 2:SUITE 104
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-2596
Practice Address - Country:US
Practice Address - Phone:239-591-4711
Practice Address - Fax:239-593-1195
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT16338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY8383Medicare UPIN