Provider Demographics
NPI:1225438237
Name:WILLIS, MARQUE
Entity Type:Individual
Prefix:
First Name:MARQUE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:772 S 2ND ST APT E
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-5858
Mailing Address - Country:US
Mailing Address - Phone:209-610-6437
Mailing Address - Fax:
Practice Address - Street 1:1401 PARKMOOR AVE
Practice Address - Street 2:230
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-3403
Practice Address - Country:US
Practice Address - Phone:408-510-3480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor