Provider Demographics
NPI:1336259860
Name:WILLOUGHBY, SEAN (MSPT, PT)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:MSPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CREDIT UNION WAY
Mailing Address - Street 2:FL. 3
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4633
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:1 PEARL ST STE 1700
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2865
Practice Address - Country:US
Practice Address - Phone:508-427-0525
Practice Address - Fax:774-223-5017
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110084875AMedicaid