Provider Demographics
NPI:1811223324
Name:WILLIS, MARY KAY (SLPA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:WILLIS
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1248 AUSTIN HWY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4821
Mailing Address - Country:US
Mailing Address - Phone:210-646-8008
Mailing Address - Fax:210-646-8242
Practice Address - Street 1:1248 AUSTIN HWY
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-4821
Practice Address - Country:US
Practice Address - Phone:210-646-8008
Practice Address - Fax:210-646-8242
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352552355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant