Provider Demographics
NPI:1235735515
Name:WILLIS, ROXANNE RAE (PHD, LSW)
Entity Type:Individual
Prefix:MS
First Name:ROXANNE
Middle Name:RAE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHD, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-2769
Mailing Address - Country:US
Mailing Address - Phone:630-947-6828
Mailing Address - Fax:
Practice Address - Street 1:213 S PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-2769
Practice Address - Country:US
Practice Address - Phone:630-947-6828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1501047411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical