Provider Demographics
NPI:1760268403
Name:ROBERTSON, WILLIS TODD (OT)
Entity Type:Individual
Prefix:
First Name:WILLIS
Middle Name:TODD
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 LONG LEAF ACRES DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-3943
Mailing Address - Country:US
Mailing Address - Phone:910-616-7110
Mailing Address - Fax:
Practice Address - Street 1:533 LONG LEAF ACRES DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3943
Practice Address - Country:US
Practice Address - Phone:910-616-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9165225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist