Provider Demographics
NPI:1821168204
Name:WILLOW THERAPEUTICS
Entity Type:Organization
Organization Name:WILLOW THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REHABILITATION MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RIOUS
Authorized Official - Middle Name:
Authorized Official - Last Name:MANABAT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:815-508-5253
Mailing Address - Street 1:24835 FRANKLIN LN
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-2216
Mailing Address - Country:US
Mailing Address - Phone:815-508-5253
Mailing Address - Fax:
Practice Address - Street 1:24835 FRANKLIN LN
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-2216
Practice Address - Country:US
Practice Address - Phone:815-508-5253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70008654225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty