Provider Demographics
NPI:1417090697
Name:WILLEMANN, TOM R (PT,OCS,MS)
Entity Type:Individual
Prefix:MR
First Name:TOM
Middle Name:R
Last Name:WILLEMANN
Suffix:
Gender:M
Credentials:PT,OCS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 CEDAR HILL AVE
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-2133
Mailing Address - Country:US
Mailing Address - Phone:201-251-2422
Mailing Address - Fax:201-857-0365
Practice Address - Street 1:541 CEDAR HILL AVE
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-2133
Practice Address - Country:US
Practice Address - Phone:201-251-2422
Practice Address - Fax:201-857-0365
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA 007709174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ200847370OtherGROUP ID
NJ039725OtherPERSONAL ID