Provider Demographics
NPI:1730139403
Name:WILLY, RICHARD WILLIAM II (MPT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:WILLIAM
Last Name:WILLY
Suffix:II
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 GRAND CENTRAL AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1079
Mailing Address - Country:US
Mailing Address - Phone:304-295-3060
Mailing Address - Fax:
Practice Address - Street 1:1500 GRAND CENTRAL AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1079
Practice Address - Country:US
Practice Address - Phone:304-295-3060
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH008881225100000X
WV001989225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7305103000Medicaid
OH2382247Medicaid
OH4060121Medicare ID - Type Unspecified