Provider Demographics
NPI:1770218844
Name:WILLIS, LAURA ABIGAIL
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ABIGAIL
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 1:1053 N RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-3840
Mailing Address - Country:US
Mailing Address - Phone:717-418-0104
Mailing Address - Fax:
Practice Address - Street 1:1007 CHURCH ST STE 302
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5912
Practice Address - Country:US
Practice Address - Phone:717-418-0104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health