Provider Demographics
NPI:1427178409
Name:WILLETTE, DOUGLAS JAMES (PTA)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:JAMES
Last Name:WILLETTE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3510 LOWDEN ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-2638
Mailing Address - Country:US
Mailing Address - Phone:269-385-5999
Mailing Address - Fax:
Practice Address - Street 1:325 N SAINT PAUL ST
Practice Address - Street 2:SUITE 4200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-3801
Practice Address - Country:US
Practice Address - Phone:866-953-0011
Practice Address - Fax:866-953-0012
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86001508A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant