Provider Demographics
NPI:1790825537
Name:WILLSON, MARK ROBERT (OT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
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 1:1035 LEIDIG DR
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-2815
Mailing Address - Country:US
Mailing Address - Phone:717-264-0956
Mailing Address - Fax:
Practice Address - Street 1:112 N 7TH ST
Practice Address - Street 2:CHAMBERSBURG HOSPITAL - PHYSICAL MEDICINE DEPARTMENT
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1720
Practice Address - Country:US
Practice Address - Phone:717-267-7715
Practice Address - Fax:717-267-7463
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC008781225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist