Provider Demographics
NPI:1700416955
Name:WILLIS, ANN BUTLER (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:BUTLER
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10325 LANSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-3523
Mailing Address - Country:US
Mailing Address - Phone:214-621-3536
Mailing Address - Fax:
Practice Address - Street 1:10325 LANSHIRE DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75238-3523
Practice Address - Country:US
Practice Address - Phone:214-621-3536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102725235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12127802OtherASHA CERTIFICATE NUMBER
TX102725OtherTEXAS SPEECH LANGUAGE PATHOLOGY LICENSE