Provider Demographics
NPI:1760682439
Name:WILLIS, KELLI (BS, CMII, RSS, CADC)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:BS, CMII, RSS, CADC
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:RENEE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:109 N FAIRLAND ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-4205
Mailing Address - Country:US
Mailing Address - Phone:918-825-1405
Mailing Address - Fax:918-825-1406
Practice Address - Street 1:109 N FAIRLAND ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4205
Practice Address - Country:US
Practice Address - Phone:918-825-1405
Practice Address - Fax:918-825-1406
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)