MEDICARE: M. RENEE WILLMS 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	104079	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0A5012	OTHER	TX	MEDICARE GROUP PTAN
2	TXB108109	OTHER	TX	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	104079	OTHER	TX	STATE
4	847T18	OTHER	TX	BCBSTX PROVIDER NUMBER

General Provider Information

NPI Number	:	1790825230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	M. RENEE WILLMS OTR

Provider Business Mailing Address
First Line	:	1825 FORTVIEW RD
Second Line	:	SUITE 103
City	:	AUSTIN
State	:	TX
Zip	:	78704-7657
Country	:	US
Telephone Number	:	512-444-4263
Fax Number	:	512-444-4264

Provider Business Practice Location Address
First Line	:	1825 FORTVIEW RD
Second Line	:	SUITE 103
City	:	AUSTIN
State	:	TX
Zip	:	78704-7657
Country	:	US
Telephone Number	:	512-444-4263
Fax Number	:	512-444-4254

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

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	03/30/2012

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Directions to “ M. RENEE WILLMS OTR” Practice Location

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