Provider Demographics
NPI:1912685454
Name:WILLIS, ERICA JO
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:JO
Last Name:WILLIS
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 1:188 MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:GREENUP
Mailing Address - State:KY
Mailing Address - Zip Code:41144-6776
Mailing Address - Country:US
Mailing Address - Phone:606-922-7371
Mailing Address - Fax:
Practice Address - Street 1:3198 MIDLAND TRL
Practice Address - Street 2:
Practice Address - City:ONA
Practice Address - State:WV
Practice Address - Zip Code:25545-9507
Practice Address - Country:US
Practice Address - Phone:304-733-9430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC1668224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant