Provider Demographics
NPI:1407024763
Name:WILLIS, DELANO ANTHONY (PHD)
Entity Type:Individual
Prefix:DR
First Name:DELANO
Middle Name:ANTHONY
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 1:13101 ALLEN RD
Mailing Address - Street 2:300
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2216
Mailing Address - Country:US
Mailing Address - Phone:734-785-7703
Mailing Address - Fax:734-785-7733
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:STE 300
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7703
Practice Address - Fax:734-785-7733
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010847103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical