Healthcare Provider Details

I. General information

NPI: 1699601500
Provider Name (Legal Business Name): ANDREW DAVID WILLIS PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 BELPAR ST NW
CANTON OH
44718-3602
US

IV. Provider business mailing address

5296 FOREST HILL DR
KENT OH
44240-5623
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-4210
  • Fax:
Mailing address:
  • Phone: 304-531-6056
  • Fax: 304-531-6056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT022438
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: