MEDICARE: MISS AMY LEA WILLIS 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	0119004482	VA

General Provider Information

NPI Number	:	1871707794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS AMY LEA WILLIS OTR

Provider Business Mailing Address
First Line	:	6804 METEOR PL APT 101
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22150-1940
Country	:	US
Telephone Number	:	765-749-0352
Fax Number	:

Provider Business Practice Location Address
First Line	:	14906 JEFFERSON DAVIS HWY
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22191-4016
Country	:	US
Telephone Number	:	703-491-5338
Fax Number	:

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

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	07/08/2007

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