Provider Demographics
NPI:1548387921
Name:WILLWERTH, DAVID ANDREW
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ANDREW
Last Name:WILLWERTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 W BOYLSTON ST
Mailing Address - Street 2:MAB COMMUNITY SERVICES
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-3071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:799 W BOYLSTON ST
Practice Address - Street 2:799 W BOYLSTON ST
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-3071
Practice Address - Country:US
Practice Address - Phone:508-854-0732
Practice Address - Fax:508-854-0733
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11223225XL0004X
NA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistLow Vision
Not Answered225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner