Provider Demographics
NPI:1609885052
Name:WILLIS, CHERYL (PTA)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 921
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0921
Mailing Address - Country:US
Mailing Address - Phone:207-942-7650
Mailing Address - Fax:207-990-5586
Practice Address - Street 1:133 CORPORATE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4312
Practice Address - Country:US
Practice Address - Phone:207-992-9286
Practice Address - Fax:207-992-9287
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1383225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME267590099Medicaid