Provider Demographics
NPI:1285751289
Name:WILLSON, KRISTY JO
Entity type:Individual
Prefix:MISS
First Name:KRISTY
Middle Name:JO
Last Name:WILLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 WALL ST APT 115
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-7668
Mailing Address - Country:US
Mailing Address - Phone:803-432-0978
Mailing Address - Fax:
Practice Address - Street 1:1001 WILDEWOOD DOWNS CIR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4434
Practice Address - Country:US
Practice Address - Phone:803-419-0431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2507224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant