Provider Demographics
NPI:1790193860
Name:WILLSON, PATRICK W (OT)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:W
Last Name:WILLSON
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 1:10540 TALBERT AVE STE 250W
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6045
Mailing Address - Country:US
Mailing Address - Phone:714-964-0727
Mailing Address - Fax:714-964-1137
Practice Address - Street 1:10540 TALBERT AVE STE 250W
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6045
Practice Address - Country:US
Practice Address - Phone:714-964-0727
Practice Address - Fax:714-964-1137
Is Sole Proprietor?:No
Enumeration Date:2014-08-01
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14503225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGMedicare PIN