Provider Demographics
NPI:1104057421
Name:WILLETTE, ANN R (DPT)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:R
Last Name:WILLETTE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:R
Other - Last Name:STROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:841 S SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4664
Practice Address - Country:US
Practice Address - Phone:866-625-3570
Practice Address - Fax:866-245-8064
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014621225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1104057421Medicaid
MI1104057421Medicaid