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General NPI Number Information
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NPI Number | 1326711169
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Entity Type | Individual
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Provider Name | MEGAN LOUISE WILLISON ATC
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Gender | Female
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Dates
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Enumeration Date | 07/28/2021
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Last Update Date | 07/28/2021
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Provider Practice Location Address
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Address Line | 1201 SYRUP MILL RD
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City | BLYTHEWOOD
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State | SC
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Zip | 29016-8493
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Country | US
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Telephone | 616-915-8690
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Fax |
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Provider Business Mailing Address
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Address Line | 112 SILO CT APT 235B
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City | COLUMBIA
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State | SC
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Zip | 29201-4975
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Country | US
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Telephone | 616-915-8690
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT03076
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License Number State | SC
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