Provider Demographics
NPI:1619298817
Name:WILLIS, TRISHA (LCSW)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:
Other - Last Name:ROARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1401 MALVERN AVE STE 180
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-6370
Mailing Address - Country:US
Mailing Address - Phone:501-385-0242
Mailing Address - Fax:
Practice Address - Street 1:1401 MALVERN AVE STE 180
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-6370
Practice Address - Country:US
Practice Address - Phone:501-385-0242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6222-C1041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
29883Medicare PIN