Healthcare Provider Details

I. General information

NPI: 1912685454
Provider Name (Legal Business Name): ERICA JO WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3198 MIDLAND TRL
ONA WV
25545-9507
US

IV. Provider business mailing address

188 MEADOWS LN
GREENUP KY
41144-6776
US

V. Phone/Fax

Practice location:
  • Phone: 304-733-9430
  • Fax:
Mailing address:
  • Phone: 606-922-7371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberC1668
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: