Provider Demographics
NPI:1598954943
Name:WILLIS, ERICA
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:
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 1:2412 GREATSTONE PT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3274
Mailing Address - Country:US
Mailing Address - Phone:859-224-4081
Mailing Address - Fax:859-224-4082
Practice Address - Street 1:2412 GREATSTONE PT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3274
Practice Address - Country:US
Practice Address - Phone:859-224-4081
Practice Address - Fax:859-224-4082
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY139121174400000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174400000XOther Service ProvidersSpecialist