MEDICARE: MRS. GABRIELLE EVELYN WILLSON

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	225XP0200X	Pediatric Occupational Therapist
2	225X00000X	Occupational Therapist	0119008364	VA

General Provider Information

NPI Number	:	1700429776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GABRIELLE EVELYN WILLSON

Provider Business Mailing Address
First Line	:	3455 VIEW AVE
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-3736
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3455 VIEW AVE
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-3736
Country	:	US
Telephone Number	:	540-484-1456
Fax Number	:

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

Provider Enumeration Date	:	10/23/2019
Last Update Date	:	01/26/2026

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