Provider Demographics
NPI:1982021515
Name:WILLOUGHBY, MARTHA MARIE (MS, OT)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:MARIE
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:MS, OT
Other - Prefix:MS
Other - First Name:M
Other - Middle Name:MARIE
Other - Last Name:WILLOUGHBY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, OT
Mailing Address - Street 1:109 HONEYSUCKLE AVE
Mailing Address - Street 2:
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-2009
Mailing Address - Country:US
Mailing Address - Phone:601-916-5741
Mailing Address - Fax:
Practice Address - Street 1:109 HONEYSUCKLE AVE
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470-2009
Practice Address - Country:US
Practice Address - Phone:601-916-5741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2125225XP0019X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation