Healthcare Provider Details

I. General information

NPI: 1710050414
Provider Name (Legal Business Name): GARY HOWARD WILLIS II O.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 06/14/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 N 4TH AVE STE A
POCATELLO ID
83201-6300
US

IV. Provider business mailing address

1030 STARS RD
CHUBBUCK ID
83202-1982
US

V. Phone/Fax

Practice location:
  • Phone: 208-604-0800
  • Fax:
Mailing address:
  • Phone: 208-604-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT593
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: