Provider Demographics
NPI:1356452205
Name:WILLETT, EDWARD T (PT)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:T
Last Name:WILLETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 GLENNIE ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-3917
Mailing Address - Country:US
Mailing Address - Phone:508-791-8740
Mailing Address - Fax:508-752-3716
Practice Address - Street 1:30 GLENNIE ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3917
Practice Address - Country:US
Practice Address - Phone:508-791-8740
Practice Address - Fax:508-752-3716
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2140225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD468025OtherTUFTS
MAY65047OtherBLUE CROSS
MA626330OtherHARVARD PILGRIM
MD0318701Medicaid
MA328820OtherCIGNA
MA64029OtherAETNA
MA981075OtherNETWORK HEALTH
MAY6504701Medicare PIN