Individual
LAWRENCE WILFONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
COTA/L
Contact information
Practice address
3148 S KINGSHIGHWAY BLVD, SAINT LOUIS, MO 63139-1118
(314) 664-4448
Mailing address
3148 S KINGSHIGHWAY BLVD, SAINT LOUIS, MO 63139-1118
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
000629
MO
Other
Enumeration date
11/08/2017
Last updated
11/08/2017
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