Provider Demographics
NPI:1790368827
Name:FLAX, WILLA
Entity Type:Individual
Prefix:
First Name:WILLA
Middle Name:
Last Name:FLAX
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 1:401 COMMONS PARK S UNIT 482
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-7136
Mailing Address - Country:US
Mailing Address - Phone:516-232-4471
Mailing Address - Fax:
Practice Address - Street 1:401 COMMONS PARK S UNIT 482
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-7136
Practice Address - Country:US
Practice Address - Phone:516-232-4471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YS0200X
NY101YS0200X
CT4895101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool