Provider Demographics
NPI:1730636010
Name:WILLIS, SANDRA LYNN (RPT)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LYNN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 REGAN CIR
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-1476
Mailing Address - Country:US
Mailing Address - Phone:508-828-2603
Mailing Address - Fax:
Practice Address - Street 1:151 REGAN CIR
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-1476
Practice Address - Country:US
Practice Address - Phone:508-828-2603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-05
Last Update Date:2016-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4794225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist