Provider Demographics
NPI:1720770613
Name:WILLIS, TERRI SHANE (LPAT)
Entity type:Individual
Prefix:MS
First Name:TERRI
Middle Name:SHANE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 PHEASANT DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-9202
Mailing Address - Country:US
Mailing Address - Phone:302-229-1723
Mailing Address - Fax:
Practice Address - Street 1:121 W COCHRAN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1302
Practice Address - Country:US
Practice Address - Phone:302-229-1723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEAT-0000003221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist