Provider Demographics
NPI:1154609303
Name:WILLEY, KIM LORRAINE (OTR/L)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:LORRAINE
Last Name:WILLEY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961 DANA HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEW HAMPTON
Mailing Address - State:NH
Mailing Address - Zip Code:03256-4534
Mailing Address - Country:US
Mailing Address - Phone:603-455-9646
Mailing Address - Fax:
Practice Address - Street 1:607 TENNEY MOUNTAIN HWY STE 144
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-3156
Practice Address - Country:US
Practice Address - Phone:603-455-9646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3257225700000X
NH1997225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist