Provider Demographics
NPI:1710199948
Name:WILLETT, PAUL D (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:D
Last Name:WILLETT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-0604
Mailing Address - Country:US
Mailing Address - Phone:309-706-3190
Mailing Address - Fax:309-452-9028
Practice Address - Street 1:1015 S MERCER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7107
Practice Address - Country:US
Practice Address - Phone:309-706-3190
Practice Address - Fax:309-452-9028
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007268103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05732025OtherBLUE CROSS BLUE SHIELD
IL117151OtherHEALTH ALLIANCE
ILK39590OtherMEDICARE