Healthcare Provider Details

I. General information

NPI: 1205148723
Provider Name (Legal Business Name): ALISA ANN WILLINGHAM OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 SHELBY PLAZA RD
SHELBINA MO
63468-1065
US

IV. Provider business mailing address

142 SHELBY PLAZA RD
SHELBINA MO
63468-1065
US

V. Phone/Fax

Practice location:
  • Phone: 573-588-4175
  • Fax: 573-588-2011
Mailing address:
  • Phone: 573-588-4175
  • Fax: 573-588-2011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2008021287
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: