Provider Demographics
NPI:1306379318
Name:WILLIS, LINDA (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 RANDOL MILL RD
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-1553
Mailing Address - Country:US
Mailing Address - Phone:817-548-3258
Mailing Address - Fax:
Practice Address - Street 1:5100 RANDOL MILL RD
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-1553
Practice Address - Country:US
Practice Address - Phone:817-548-3258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101295235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist