Provider Demographics
NPI:1740603570
Name:WILLIS, BEVERLY
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9367 TWO NOTCH RD
Mailing Address - Street 2:SUITE C2
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6442
Mailing Address - Country:US
Mailing Address - Phone:404-956-2691
Mailing Address - Fax:803-661-1093
Practice Address - Street 1:9367 TWO NOTCH RD
Practice Address - Street 2:SUITE C2
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6442
Practice Address - Country:US
Practice Address - Phone:404-956-2691
Practice Address - Fax:803-661-1093
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101Y00000XBehavioral Health & Social Service ProvidersCounselor