Provider Demographics
NPI:1528374907
Name:WILLIS, NANCY JEAN (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:JEAN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:NANCY
Other - Middle Name:JEAN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:109 HERKIMER ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-1711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:819 S SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3527
Practice Address - Country:US
Practice Address - Phone:315-476-7921
Practice Address - Fax:315-474-1448
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-07172104100000X
NY081889-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400040984Medicare PIN