Provider Demographics
NPI:1548579121
Name:WILLIS CENTER
Entity Type:Organization
Organization Name:WILLIS CENTER
Other - Org Name:HENRY LEE WILLIS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:SANSOUCY
Authorized Official - Suffix:
Authorized Official - Credentials:MA CAGS LMHC
Authorized Official - Phone:508-799-2934
Mailing Address - Street 1:91 KENBERMA ROAD
Mailing Address - Street 2:APARTMENT #2
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604
Mailing Address - Country:US
Mailing Address - Phone:508-479-9310
Mailing Address - Fax:
Practice Address - Street 1:44 FRONT ST
Practice Address - Street 2:FOURTH FLOOR
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1733
Practice Address - Country:US
Practice Address - Phone:508-799-2934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6707324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility