Provider Demographics
NPI:1326700246
Name:WILLIS, ASHLEY N (BSW)
Entity Type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:N
Last Name:WILLIS
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 SIMPSON DR
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MS
Mailing Address - Zip Code:38967-3009
Mailing Address - Country:US
Mailing Address - Phone:662-508-5116
Mailing Address - Fax:
Practice Address - Street 1:515 SIMPSON DR
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-3009
Practice Address - Country:US
Practice Address - Phone:662-508-5116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRBT-21-182914106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician