=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306493002
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN VIRGINIA WILLIS PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2019
-----------------------------------------------------
Last Update Date | 03/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12476 W NEVADA PL APT 106
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80228-3251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-304-6160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4950 LARKSPUR ST.
-----------------------------------------------------
City | BOW MAR
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-304-6160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PTL.0016586
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------