Provider Demographics
NPI:1114192051
Name:WILLIS, LISA (BGS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:BGS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BGS
Mailing Address - Street 1:1015 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1526
Mailing Address - Country:US
Mailing Address - Phone:574-722-5151
Mailing Address - Fax:574-739-1414
Practice Address - Street 1:655 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-2662
Practice Address - Country:US
Practice Address - Phone:765-472-1931
Practice Address - Fax:765-472-1945
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator