Provider Demographics
NPI:1417313263
Name:WILLIS, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10077 INFINITY LN
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-7512
Mailing Address - Country:US
Mailing Address - Phone:937-541-8433
Mailing Address - Fax:
Practice Address - Street 1:10077 INFINITY LN
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-7512
Practice Address - Country:US
Practice Address - Phone:937-541-8433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-10
Last Update Date:2016-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA 10311225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant