Healthcare Provider Details

I. General information

NPI: 1073614285
Provider Name (Legal Business Name): ADAM M WILLIS P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 GLEN ST SUITE #52
GLENS FALLS NY
12801-3584
US

IV. Provider business mailing address

221 MAIN ST
SOUTH GLENS FALLS NY
12803-5118
US

V. Phone/Fax

Practice location:
  • Phone: 518-538-8778
  • Fax: 518-636-3204
Mailing address:
  • Phone: 518-225-5049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305204833
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00010625
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number027046-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: