Provider Demographics
NPI:1841807690
Name:WILLIS, SHELBY S (DPT)
Entity type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:S
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17453 HIGHWAY 432
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-4022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1181 HWY 432
Practice Address - Street 2:
Practice Address - City:SLAUGHTER
Practice Address - State:LA
Practice Address - Zip Code:70777
Practice Address - Country:US
Practice Address - Phone:225-306-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist