Provider Demographics
NPI:1689912248
Name:WILLS, KATHLEEN ANNE (BA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANNE
Last Name:WILLS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:ANNE
Other - Last Name:WILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:631 WOODSIDE RD
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-3847
Mailing Address - Country:US
Mailing Address - Phone:805-890-9247
Mailing Address - Fax:
Practice Address - Street 1:631 WOODSIDE RD
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94061-3847
Practice Address - Country:US
Practice Address - Phone:805-890-9247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94024326101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)