Provider Demographics
NPI:1083932859
Name:WILLIS, GAY FONTAINA (BHRS CM)
Entity Type:Individual
Prefix:MISS
First Name:GAY
Middle Name:FONTAINA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:BHRS CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-3464
Mailing Address - Country:US
Mailing Address - Phone:405-610-6675
Mailing Address - Fax:
Practice Address - Street 1:1015 WATERWOOD PKWY
Practice Address - Street 2:G-N2
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5327
Practice Address - Country:US
Practice Address - Phone:405-863-2224
Practice Address - Fax:405-285-1652
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor