Provider Demographics
NPI:1144857343
Name:WILLIS, DIANE THERESE (LMT)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:THERESE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:THERESE
Other - Last Name:GLANCEY WILLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:580 FOXTAIL DR APT 101
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-2492
Mailing Address - Country:US
Mailing Address - Phone:262-719-4349
Mailing Address - Fax:
Practice Address - Street 1:580 FOXTAIL DR APT 101
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-2492
Practice Address - Country:US
Practice Address - Phone:262-719-4349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12802-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist