Provider Demographics
NPI:1740427772
Name:WILLISON, KRISTY NICOLE (OT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:NICOLE
Last Name:WILLISON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MISS
Other - First Name:KRISTY
Other - Middle Name:NICOLE
Other - Last Name:COPENHAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4645 BELPAR ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3602
Mailing Address - Country:US
Mailing Address - Phone:330-493-4210
Mailing Address - Fax:330-493-4744
Practice Address - Street 1:4645 BELPAR ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3602
Practice Address - Country:US
Practice Address - Phone:330-493-4210
Practice Address - Fax:330-493-4744
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2009-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT-005929225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist