Provider Demographics
NPI:1023184264
Name:WILLIS, SHIRLEY ANNE (PHD)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:ANNE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 W INTERSTATE 20
Mailing Address - Street 2:BLDG. HR-II, STE. 206
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-7620
Mailing Address - Country:US
Mailing Address - Phone:814-466-2585
Mailing Address - Fax:817-466-2596
Practice Address - Street 1:2340 W INTERSTATE 20
Practice Address - Street 2:BLDG. HR-II, STE. 206
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-7620
Practice Address - Country:US
Practice Address - Phone:814-466-2585
Practice Address - Fax:817-466-2596
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21860103T00000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096833101Medicaid
TX00H45ROtherBCBS
TX096833101Medicaid
00H45RTXMedicare PIN
TX135238706Medicare UPIN