Basic Information
| Provider Information | |||||||||
| NPI: | 1366672263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLISTON | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | CHERYL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREENING | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | CHERYL | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2237 US HIGHWAY 2 E | ||||||||
| Address2: | SUITE B | ||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599012812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067567878 | ||||||||
| FaxNumber: | 4063092579 | ||||||||
| Practice Location | |||||||||
| Address1: | 5988 STETSON HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809233567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195743111 | ||||||||
| FaxNumber: | 7195742912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2009 | ||||||||
| LastUpdateDate: | 01/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTL.0012052 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.