Provider Demographics
NPI:1508314568
Name:WILLS, DAVID A (LICDC-CS, LPC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:WILLS
Suffix:
Gender:M
Credentials:LICDC-CS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 MARKET AVE N
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1017
Mailing Address - Country:US
Mailing Address - Phone:330-327-4826
Mailing Address - Fax:
Practice Address - Street 1:1375 RAFF RD SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44710-2317
Practice Address - Country:US
Practice Address - Phone:330-479-1912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC2285101YM0800X
OH872350101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0189603Medicaid