Provider Demographics
NPI:1083700652
Name:WILLIS, MARY (LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073
Mailing Address - Country:US
Mailing Address - Phone:540-392-0711
Mailing Address - Fax:
Practice Address - Street 1:4656 BRAMBLETON AVENUE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018
Practice Address - Country:US
Practice Address - Phone:540-772-8043
Practice Address - Fax:540-772-8242
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003372101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA087515MOtherSOUTHERN HEALTH
VA488754OtherVALUE OPTIONS
TX7684485OtherAETNA
VA191801OtherANTHEM BCBS