Provider Demographics
NPI:1003346024
Name:WILLIS, SHALONDA ELANE
Entity Type:Individual
Prefix:
First Name:SHALONDA
Middle Name:ELANE
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 1:2525 YOUREE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3600
Mailing Address - Country:US
Mailing Address - Phone:318-742-3408
Mailing Address - Fax:
Practice Address - Street 1:122 DESOTO AVE STE 109
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-4440
Practice Address - Country:US
Practice Address - Phone:662-592-5397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker