Provider Demographics
NPI:1699274407
Name:WILLIS, ELIZABETH (COTA/L)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8026 W CORRINE DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-9034
Mailing Address - Country:US
Mailing Address - Phone:509-995-5232
Mailing Address - Fax:
Practice Address - Street 1:1235 E HARMONT DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3864
Practice Address - Country:US
Practice Address - Phone:602-331-1470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7177224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ82-4292737OtherIRS