Provider Demographics
NPI:1710050414
Name:WILLIS, GARY HOWARD II (OT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:HOWARD
Last Name:WILLIS
Suffix:II
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 WYLDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3644
Mailing Address - Country:US
Mailing Address - Phone:208-604-0800
Mailing Address - Fax:208-232-5770
Practice Address - Street 1:4473 FOX CT
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2670
Practice Address - Country:US
Practice Address - Phone:208-604-0800
Practice Address - Fax:208-232-5770
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT593225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist