Healthcare Provider Details

I. General information

NPI: 1912998311
Provider Name (Legal Business Name): STEPHEN MATTHEW WILLEY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 12/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 DALE RD
MODESTO CA
95356-9718
US

IV. Provider business mailing address

4601 DALE RD
MODESTO CA
95356-9718
US

V. Phone/Fax

Practice location:
  • Phone: 209-735-4080
  • Fax: 209-735-4060
Mailing address:
  • Phone: 209-735-4080
  • Fax: 209-735-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT25761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: