Provider Demographics
NPI:1629299664
Name:WILLIS, WESLEY DEMARIUS (PSYD, LCSW-R, RN)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:DEMARIUS
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PSYD, LCSW-R, RN
Other - Prefix:
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Mailing Address - Street 1:3016 31ST ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2269
Mailing Address - Country:US
Mailing Address - Phone:347-502-0965
Mailing Address - Fax:718-559-6473
Practice Address - Street 1:1740 BROADWAY FL 15
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4605
Practice Address - Country:US
Practice Address - Phone:347-502-0965
Practice Address - Fax:917-725-8319
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY0767291041C0700X
NY650621163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03152545Medicaid
NY03152545Medicaid