Provider Demographics
NPI:1588181093
Name:WILLIS, MONIQUE RENEE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:RENEE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12140 CALLE SOMBRA APT 126
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7056
Mailing Address - Country:US
Mailing Address - Phone:909-697-8172
Mailing Address - Fax:
Practice Address - Street 1:1905 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3460
Practice Address - Country:US
Practice Address - Phone:909-289-1041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst