MEDICARE: ALISA ANN WILLINGHAM OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	2008021287	MO

General Provider Information

NPI Number	:	1205148723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISA ANN WILLINGHAM OTR

Provider Business Mailing Address
First Line	:	142 SHELBY PLAZA RD
Second Line	:
City	:	SHELBINA
State	:	MO
Zip	:	63468-1065
Country	:	US
Telephone Number	:	573-588-4175
Fax Number	:	573-588-2011

Provider Business Practice Location Address
First Line	:	142 SHELBY PLAZA RD
Second Line	:
City	:	SHELBINA
State	:	MO
Zip	:	63468-1065
Country	:	US
Telephone Number	:	573-588-4175
Fax Number	:	573-588-2011

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2010
Last Update Date	:	07/13/2010

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