Provider Demographics
NPI:1780190132
Name:WILLIS, MYCHOLE (SSP)
Entity Type:Individual
Prefix:
First Name:MYCHOLE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 E ELMWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1104
Mailing Address - Country:US
Mailing Address - Phone:708-647-7019
Mailing Address - Fax:
Practice Address - Street 1:41 E ELMWOOD DR
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-1104
Practice Address - Country:US
Practice Address - Phone:708-647-7019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2289879103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool