Provider Demographics
NPI:1891130688
Name:WILLIS, KENNYON GLENN
Entity Type:Individual
Prefix:
First Name:KENNYON
Middle Name:GLENN
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 1:1209 W HEFNER RD
Mailing Address - Street 2:APT 162
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-7007
Mailing Address - Country:US
Mailing Address - Phone:405-305-9476
Mailing Address - Fax:
Practice Address - Street 1:1209 W HEFNER RD
Practice Address - Street 2:APT 162
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-7007
Practice Address - Country:US
Practice Address - Phone:405-305-9476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional