Provider Demographics
NPI:1477090595
Name:WILLMANN, MAHALA (RBT)
Entity Type:Individual
Prefix:
First Name:MAHALA
Middle Name:
Last Name:WILLMANN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1054 PURDUE DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-3650
Mailing Address - Country:US
Mailing Address - Phone:720-253-2868
Mailing Address - Fax:
Practice Address - Street 1:1054 PURDUE DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-3650
Practice Address - Country:US
Practice Address - Phone:720-253-2868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-15-10990106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician