Provider Demographics
NPI:1598361511
Name:WILLIS, WILMA JEAN
Entity Type:Individual
Prefix:
First Name:WILMA
Middle Name:JEAN
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 1:2876 SIMMENTAL LN
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OK
Mailing Address - Zip Code:73448-7341
Mailing Address - Country:US
Mailing Address - Phone:580-795-4608
Mailing Address - Fax:
Practice Address - Street 1:2876 SIMMENTAL LN
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OK
Practice Address - Zip Code:73448-7341
Practice Address - Country:US
Practice Address - Phone:580-795-4608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2022-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator