Provider Demographics
NPI:1679943500
Name:WILLIS, VANITA
Entity Type:Individual
Prefix:
First Name:VANITA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VANITA
Other - Middle Name:
Other - Last Name:CALDWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:237 OILFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DUBACH
Mailing Address - State:LA
Mailing Address - Zip Code:71235-2933
Mailing Address - Country:US
Mailing Address - Phone:318-497-2258
Mailing Address - Fax:
Practice Address - Street 1:237 OILFIELD RD
Practice Address - Street 2:
Practice Address - City:DUBACH
Practice Address - State:LA
Practice Address - Zip Code:71235-2933
Practice Address - Country:US
Practice Address - Phone:318-497-2258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1003279654Medicaid