Provider Demographics
NPI:1497966881
Name:WILLIS, ROBERT (RRW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19100 VENTURA BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3239
Mailing Address - Country:US
Mailing Address - Phone:818-654-2577
Mailing Address - Fax:818-654-2580
Practice Address - Street 1:19100 VENTURA BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3239
Practice Address - Country:US
Practice Address - Phone:818-654-2577
Practice Address - Fax:818-654-2580
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW0303101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)