Provider Demographics
NPI:1275733883
Name:WILLIS, KEITH ALLAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALLAN
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 N 4TH ST STE 108
Mailing Address - Street 2:
Mailing Address - City:ONEILL
Mailing Address - State:NE
Mailing Address - Zip Code:68763-1317
Mailing Address - Country:US
Mailing Address - Phone:402-336-1306
Mailing Address - Fax:
Practice Address - Street 1:614 N 4TH ST STE 108
Practice Address - Street 2:
Practice Address - City:ONEILL
Practice Address - State:NE
Practice Address - Zip Code:68763-1317
Practice Address - Country:US
Practice Address - Phone:402-336-1306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE268870Medicare UPIN