Provider Demographics
NPI:1134518814
Name:WILLING, ALEX
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:WILLING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1038 BABCOCK ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3680
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 BYRD AVE
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4015
Practice Address - Country:US
Practice Address - Phone:920-725-2714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-18
Last Update Date:2021-10-18
Deactivation Date:2019-08-05
Deactivation Code:
Reactivation Date:2021-10-18
Provider Licenses
StateLicense IDTaxonomies
WI2189-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1668Medicaid