Provider Demographics
NPI:1548735764
Name:WILLIS, JULEANNA (CT-AD)
Entity Type:Individual
Prefix:
First Name:JULEANNA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CT-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 RIVERSIDE DR STE 7
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5352
Mailing Address - Country:US
Mailing Address - Phone:410-548-3333
Mailing Address - Fax:
Practice Address - Street 1:540 RIVERSIDE DR STE 7
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5352
Practice Address - Country:US
Practice Address - Phone:410-548-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT1742101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty