Provider Demographics
NPI:1164143541
Name:WILLIS, OLIVIA HADLEY (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:HADLEY
Last Name:WILLIS
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BUFFALO AVE NW STE 2207
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 S RIDGE AVE
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-4008
Practice Address - Country:US
Practice Address - Phone:980-242-0690
Practice Address - Fax:980-236-9380
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15193225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist