Provider Demographics
NPI:1073706941
Name:WILLIS, DARRELLE (MS)
Entity Type:Individual
Prefix:
First Name:DARRELLE
Middle Name:
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 1:103 SOUTHLAKE CIR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-5369
Mailing Address - Country:US
Mailing Address - Phone:601-859-8371
Mailing Address - Fax:601-859-5433
Practice Address - Street 1:45 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2337
Practice Address - Country:US
Practice Address - Phone:731-664-2083
Practice Address - Fax:731-664-1988
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor