Provider Demographics
NPI:1457854119
Name:WILLETT, ARIELLE (ATC, ITAT)
Entity Type:Individual
Prefix:
First Name:ARIELLE
Middle Name:
Last Name:WILLETT
Suffix:
Gender:F
Credentials:ATC, ITAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22044 W MILLER CT
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-6053
Mailing Address - Country:US
Mailing Address - Phone:708-912-2256
Mailing Address - Fax:
Practice Address - Street 1:505 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-4005
Practice Address - Country:US
Practice Address - Phone:708-386-0127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0039202081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine