Provider Demographics
NPI:1265628366
Name:WILLEMEN, MARK (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:WILLEMEN
Suffix:
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 1:1440 51ST CT
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32966-2340
Mailing Address - Country:US
Mailing Address - Phone:772-643-5993
Mailing Address - Fax:
Practice Address - Street 1:495 22ND PL
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6002
Practice Address - Country:US
Practice Address - Phone:772-567-8585
Practice Address - Fax:772-299-7868
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 21015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT 21015OtherPHYSICAL THERAPY LICENSE