Provider Demographics
NPI:1255809471
Name:WILLIS, SALLY (MOT, OTR/L, CBIS)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MOT, OTR/L, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6621 FANNIN ST FL 21
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2399
Mailing Address - Country:US
Mailing Address - Phone:832-826-2121
Mailing Address - Fax:832-825-0584
Practice Address - Street 1:6621 FANNIN ST FL 21
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2399
Practice Address - Country:US
Practice Address - Phone:832-826-2121
Practice Address - Fax:832-825-0584
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117512225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist