Provider Demographics
NPI:1790135549
Name:WILLIS, KELLEY (MSW)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14900 BOGLE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1756
Mailing Address - Country:US
Mailing Address - Phone:703-817-9890
Mailing Address - Fax:703-817-9860
Practice Address - Street 1:14900 BOGLE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1756
Practice Address - Country:US
Practice Address - Phone:703-817-9890
Practice Address - Fax:703-817-9860
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor