Provider Demographics
NPI:1821624495
Name:WILLIS, CASSIUS MUSA
Entity Type:Individual
Prefix:
First Name:CASSIUS
Middle Name:MUSA
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 S MAIN ST STE 401
Mailing Address - Street 2:
Mailing Address - City:S SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2677
Mailing Address - Country:US
Mailing Address - Phone:310-993-6631
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1700
Practice Address - Country:US
Practice Address - Phone:801-322-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator