Provider Demographics
NPI:1689726051
Name:WILLIS, REBECA P (MA,MFT)
Entity Type:Individual
Prefix:MRS
First Name:REBECA
Middle Name:P
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MA,MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 DARBY RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2425
Mailing Address - Country:US
Mailing Address - Phone:626-943-9193
Mailing Address - Fax:
Practice Address - Street 1:2304 HUNTINGTON DR
Practice Address - Street 2:254
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-2649
Practice Address - Country:US
Practice Address - Phone:626-943-9193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFCT 13018174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist