Provider Demographics
NPI:1407077761
Name:WILLIS, ELIZABETH SMITH (MSP, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:SMITH
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 EQUESTRIAN DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3608
Mailing Address - Country:US
Mailing Address - Phone:803-622-6505
Mailing Address - Fax:
Practice Address - Street 1:940 EQUESTRIAN DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3608
Practice Address - Country:US
Practice Address - Phone:803-622-6505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3856235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist