Provider Demographics
NPI:1891106696
Name:WILLIS, LYNSON (ATC, CES)
Entity Type:Individual
Prefix:
First Name:LYNSON
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 CROWN ST APT 5I
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-1871
Mailing Address - Country:US
Mailing Address - Phone:914-457-1992
Mailing Address - Fax:
Practice Address - Street 1:35 CROWN ST APT 5I
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-1871
Practice Address - Country:US
Practice Address - Phone:914-457-1992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001988-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer