Provider Demographics
NPI:1790989978
Name:WILLIS, BRENDA L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 25TH RD
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-3427
Mailing Address - Country:US
Mailing Address - Phone:816-213-9775
Mailing Address - Fax:
Practice Address - Street 1:1332 SURF AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224
Practice Address - Country:US
Practice Address - Phone:718-449-4000
Practice Address - Fax:718-449-5146
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050150721041C0700X
NY0776481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical