Healthcare Provider Details

I. General information

NPI: 1124747050
Provider Name (Legal Business Name): CALEB WILLIS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 GREENE ST
WEBSTER TX
77598-6701
US

IV. Provider business mailing address

9 MIRA LOMA DR
MANVEL TX
77578-3347
US

V. Phone/Fax

Practice location:
  • Phone: 281-332-4738
  • Fax:
Mailing address:
  • Phone: 903-279-8531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2141147
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: