Provider Demographics
NPI:1215163530
Name:WILLISTON, ERIC (DPT)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:WILLISTON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 BRIARGATE PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7837
Mailing Address - Country:US
Mailing Address - Phone:443-386-4880
Mailing Address - Fax:
Practice Address - Street 1:4110 BRIARGATE PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7835
Practice Address - Country:US
Practice Address - Phone:719-632-7669
Practice Address - Fax:719-867-7336
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-01
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0012040225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist