Provider Demographics
NPI:1851634521
Name:WILLIS, DEREK A (DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:A
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 EAGLE ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:EAST HANOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07936
Mailing Address - Country:US
Mailing Address - Phone:973-887-9000
Mailing Address - Fax:973-887-3816
Practice Address - Street 1:80 EAST RIDWOOD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652
Practice Address - Country:US
Practice Address - Phone:201-652-1415
Practice Address - Fax:201-652-0391
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01490500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist