Provider Demographics
NPI:1205148723
Name:WILLINGHAM, ALISA ANN (OTR)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:ANN
Last Name:WILLINGHAM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 SHELBY PLAZA RD
Mailing Address - Street 2:
Mailing Address - City:SHELBINA
Mailing Address - State:MO
Mailing Address - Zip Code:63468-1065
Mailing Address - Country:US
Mailing Address - Phone:573-588-4175
Mailing Address - Fax:573-588-2011
Practice Address - Street 1:142 SHELBY PLAZA RD
Practice Address - Street 2:
Practice Address - City:SHELBINA
Practice Address - State:MO
Practice Address - Zip Code:63468-1065
Practice Address - Country:US
Practice Address - Phone:573-588-4175
Practice Address - Fax:573-588-2011
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008021287225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist