Provider Demographics
NPI:1467801340
Name:WILLIS, THAD JUSTIN (DPT)
Entity Type:Individual
Prefix:
First Name:THAD
Middle Name:JUSTIN
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:JUSTIN
Other - Middle Name:
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:2002 W SUNSET DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2283
Mailing Address - Country:US
Mailing Address - Phone:307-856-7021
Mailing Address - Fax:307-856-5546
Practice Address - Street 1:2002 W SUNSET DR
Practice Address - Street 2:SUITE 1
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2283
Practice Address - Country:US
Practice Address - Phone:307-856-7021
Practice Address - Fax:307-856-5546
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-1633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist