Provider Demographics
NPI:1851536692
Name:WILLIS, WILLIAM R (PT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-1257
Mailing Address - Country:US
Mailing Address - Phone:814-362-7466
Mailing Address - Fax:814-362-9803
Practice Address - Street 1:20 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1257
Practice Address - Country:US
Practice Address - Phone:814-362-7466
Practice Address - Fax:814-362-9803
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006299L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist