Provider Demographics
NPI:1528947371
Name:WILLARD, ELYSIA S (LMT)
Entity type:Individual
Prefix:
First Name:ELYSIA
Middle Name:S
Last Name:WILLARD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 JACQUELINE CIR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-7883
Mailing Address - Country:US
Mailing Address - Phone:314-791-3088
Mailing Address - Fax:
Practice Address - Street 1:2627 METRO BLVD
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-2411
Practice Address - Country:US
Practice Address - Phone:314-791-3088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013014519225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist