Provider Demographics
NPI:1255752010
Name:WILLARD, BEVERLY GOODRICH (PT)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:GOODRICH
Last Name:WILLARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 PLATEAU PL
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21409-5133
Mailing Address - Country:US
Mailing Address - Phone:410-757-2265
Mailing Address - Fax:
Practice Address - Street 1:273 PENINSULA FARM RD
Practice Address - Street 2:BUILDING 2 SUITE C
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-1012
Practice Address - Country:US
Practice Address - Phone:410-975-5343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-21
Last Update Date:2013-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16378225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist