Provider Demographics
NPI:1043747926
Name:WILLIS, D'UNDRA (LICSW)
Entity Type:Individual
Prefix:
First Name:D'UNDRA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 W BROADWAY AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-2531
Mailing Address - Country:US
Mailing Address - Phone:763-886-4218
Mailing Address - Fax:
Practice Address - Street 1:1011 W BROADWAY AVE STE 110
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-2531
Practice Address - Country:US
Practice Address - Phone:612-886-4218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN236481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN23648OtherMN BOARD OF SW
MNQ577186700819OtherDRIVERS LISCENSE