Provider Demographics
NPI:1710551411
Name:WILLETT, ALYSE MATLOCK (LPC)
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:MATLOCK
Last Name:WILLETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E SOUTH ST STE 5
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-5217
Mailing Address - Country:US
Mailing Address - Phone:972-499-5561
Mailing Address - Fax:
Practice Address - Street 1:100 E SOUTH ST STE 5
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5217
Practice Address - Country:US
Practice Address - Phone:972-499-5561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76174101YP2500X
VA0701010444101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional