Basic Information
| Provider Information | |||||||||
| NPI: | 1134518814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLING | ||||||||
| FirstName: | ALEX | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1038 BABCOCK ST | ||||||||
| Address2: | |||||||||
| City: | NEENAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549563680 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 125 BYRD AVE | ||||||||
| Address2: | |||||||||
| City: | NEENAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549564015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207252714 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2015 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/05/2019 | ||||||||
| NPIReactivationDate: | 10/18/2021 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2189-19 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1668 | 05 | WI | MEDICAID |