Provider Demographics
NPI:1790303295
Name:WILLSON, MCKENZIE SUE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:SUE
Last Name:WILLSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 243
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84542-0243
Mailing Address - Country:US
Mailing Address - Phone:435-559-0096
Mailing Address - Fax:
Practice Address - Street 1:300 N HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-4218
Practice Address - Country:US
Practice Address - Phone:435-637-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11822534-4202224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant