Basic Information
| Provider Information | |||||||||
| NPI: | 1013201037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH MILLER | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3485 GREENWAY DR | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308094276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126570140 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1120 15TH ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309122865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067212273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2011 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT005159 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.