Provider Demographics
NPI:1275806572
Name:WILLIS, DEANNA (MS CF SLP)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MS CF SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 NORMANDIE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-4732
Mailing Address - Country:US
Mailing Address - Phone:208-323-8888
Mailing Address - Fax:
Practice Address - Street 1:6855 W FAIRVIEW AVE
Practice Address - Street 2:STER 120
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8046
Practice Address - Country:US
Practice Address - Phone:208-323-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist