Provider Demographics
NPI:1093292526
Name:WILLIS, VALERIE R
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:R
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18600 W 10 MILE RD STE 112
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2645
Mailing Address - Country:US
Mailing Address - Phone:248-632-0003
Mailing Address - Fax:313-736-3340
Practice Address - Street 1:18600 W 10 MILE RD STE 112
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2645
Practice Address - Country:US
Practice Address - Phone:248-632-0003
Practice Address - Fax:313-736-3340
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies