Provider Demographics
NPI:1700021425
Name:WILLIS, JOHN GLEN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GLEN
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 JOHNSON RD STE 286
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-6003
Mailing Address - Country:US
Mailing Address - Phone:720-220-4187
Mailing Address - Fax:
Practice Address - Street 1:1030 JOHNSON RD STE 286
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-6003
Practice Address - Country:US
Practice Address - Phone:720-220-4187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6334101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO14467331OtherCAQH