Provider Demographics
NPI:1952660805
Name:WILLIS, TERESA MAE (COTA/L)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MAE
Last Name:WILLIS
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 1:881 BIFROST WAY
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:VA
Mailing Address - Zip Code:22642-5931
Mailing Address - Country:US
Mailing Address - Phone:480-291-2380
Mailing Address - Fax:
Practice Address - Street 1:881 BIFROST WAY
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:VA
Practice Address - Zip Code:22642-5931
Practice Address - Country:US
Practice Address - Phone:480-291-2380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000537224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant