Provider Demographics
NPI:1962665554
Name:WILLIAMSON, FAILICA RENEE (COTA)
Entity Type:Individual
Prefix:
First Name:FAILICA
Middle Name:RENEE
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27597 PARKVIEW BLVD APT 9206
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2945
Mailing Address - Country:US
Mailing Address - Phone:313-978-6622
Mailing Address - Fax:
Practice Address - Street 1:4646 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1916
Practice Address - Country:US
Practice Address - Phone:313-576-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202002630224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant