=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255187068
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLOW TREE PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2024
-----------------------------------------------------
Last Update Date | 04/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 US HIGHWAY 23 N STE 2
-----------------------------------------------------
City | ALPENA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49707-1279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-884-3128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 US HIGHWAY 23 N STE 2
-----------------------------------------------------
City | ALPENA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49707-1279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-884-3128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WYNNE TEZAK
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 989-884-3128
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------