Provider Demographics
NPI:1588185946
Name:WILLEY, DANIEL WESLEY JR
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:WESLEY
Last Name:WILLEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 INNOVATION DR
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-8096
Mailing Address - Country:US
Mailing Address - Phone:724-343-4060
Mailing Address - Fax:724-343-4069
Practice Address - Street 1:870 GORDON NAGLE TRL STE 100
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-4203
Practice Address - Country:US
Practice Address - Phone:570-399-5331
Practice Address - Fax:570-399-5374
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT026091225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019541330001Medicaid