Provider Demographics
NPI:1477559334
Name:WILLIS, WENDY I (LCSW)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:I
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 413
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47151-0413
Mailing Address - Country:US
Mailing Address - Phone:812-206-3291
Mailing Address - Fax:812-206-3296
Practice Address - Street 1:229 W SPRING ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-3641
Practice Address - Country:US
Practice Address - Phone:812-206-3291
Practice Address - Fax:812-206-3296
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004562104100000X
KY1650104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8200051400Medicaid
IN160860UOtherMEDICARE
KY8200051400Medicaid