Provider Demographics
NPI:1851401749
Name:WILLIS, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:WILLIS
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 1:6891 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEIGHTON
Mailing Address - State:AL
Mailing Address - Zip Code:35646-3540
Mailing Address - Country:US
Mailing Address - Phone:256-446-6809
Mailing Address - Fax:
Practice Address - Street 1:1302 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-2236
Practice Address - Country:US
Practice Address - Phone:256-386-0885
Practice Address - Fax:256-386-0895
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPTH3364OtherLICENSE #