Provider Demographics
NPI:1407472657
Name:WILLEY, DANIEL M
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:M
Last Name:WILLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2519 COVE AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-3910
Mailing Address - Country:US
Mailing Address - Phone:541-962-0830
Mailing Address - Fax:
Practice Address - Street 1:2519 COVE AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3910
Practice Address - Country:US
Practice Address - Phone:541-962-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR65160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health