Provider Demographics
NPI:1245401157
Name:WILLIS, LYNDA JILL (PTA)
Entity Type:Individual
Prefix:
First Name:LYNDA
Middle Name:JILL
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11910 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-6827
Mailing Address - Country:US
Mailing Address - Phone:337-540-7163
Mailing Address - Fax:
Practice Address - Street 1:11910 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-6827
Practice Address - Country:US
Practice Address - Phone:337-540-7163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2036671225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant