Provider Demographics
NPI:1568677748
Name:WILLIS, RICHARD G (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2495
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24402-2495
Mailing Address - Country:US
Mailing Address - Phone:540-255-1354
Mailing Address - Fax:540-213-0620
Practice Address - Street 1:1301 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-9146
Practice Address - Country:US
Practice Address - Phone:540-255-1354
Practice Address - Fax:540-213-0620
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3774103T00000X
VA0810002852103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist