Provider Demographics
NPI:1598834848
Name:WILLARD, LAURA R
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:R
Last Name:WILLARD
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 1:481 ASHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75069-8547
Mailing Address - Country:US
Mailing Address - Phone:972-542-8318
Mailing Address - Fax:
Practice Address - Street 1:2931 RIDGE RD STE 115
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6669
Practice Address - Country:US
Practice Address - Phone:972-771-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1135424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist