Provider Demographics
NPI:1851649701
Name:WILLIS, CASEY ELIZABETH (BCABA)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:ELIZABETH
Last Name:WILLIS
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 EVENING SHADE
Mailing Address - Street 2:
Mailing Address - City:HARVEST
Mailing Address - State:AL
Mailing Address - Zip Code:35749-4875
Mailing Address - Country:US
Mailing Address - Phone:256-651-3972
Mailing Address - Fax:
Practice Address - Street 1:106 EVENING SHADE
Practice Address - Street 2:
Practice Address - City:HARVEST
Practice Address - State:AL
Practice Address - Zip Code:35749-4875
Practice Address - Country:US
Practice Address - Phone:256-651-3972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0-17-7780106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst