Provider Demographics
NPI:1053857722
Name:WILLIS, KACI DAWN (MS)
Entity Type:Individual
Prefix:MRS
First Name:KACI
Middle Name:DAWN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 WILLIS SPRING RD
Mailing Address - Street 2:
Mailing Address - City:EAGLETOWN
Mailing Address - State:OK
Mailing Address - Zip Code:74734-3413
Mailing Address - Country:US
Mailing Address - Phone:870-784-1147
Mailing Address - Fax:
Practice Address - Street 1:110 WILLIS SPRING RD
Practice Address - Street 2:
Practice Address - City:EAGLETOWN
Practice Address - State:OK
Practice Address - Zip Code:74734-3413
Practice Address - Country:US
Practice Address - Phone:870-784-1147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#P9074235Z00000X
TX112453235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist