Provider Demographics
NPI:1568645414
Name:WILLIS, JANICE ELAINE (MS, LCPC)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:ELAINE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:ELAINE
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LCPC
Mailing Address - Street 1:111 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3754
Mailing Address - Country:US
Mailing Address - Phone:309-757-0300
Mailing Address - Fax:309-757-0400
Practice Address - Street 1:111 19TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3754
Practice Address - Country:US
Practice Address - Phone:309-757-0300
Practice Address - Fax:309-757-0400
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.005363101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional