Provider Demographics
NPI:1578617817
Name:WILLARD, ANDREA JEAN (PT)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:JEAN
Last Name:WILLARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2914 MOSS AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-4227
Mailing Address - Country:US
Mailing Address - Phone:432-689-7515
Mailing Address - Fax:
Practice Address - Street 1:501 ANDREWS HWY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5818
Practice Address - Country:US
Practice Address - Phone:432-570-7587
Practice Address - Fax:432-620-6675
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1120202225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist