Provider Demographics
NPI:1891470381
Name:WILLIS, SHAKIRA MARIE
Entity Type:Individual
Prefix:
First Name:SHAKIRA
Middle Name:MARIE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 CURTICE ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2566
Mailing Address - Country:US
Mailing Address - Phone:651-808-3381
Mailing Address - Fax:
Practice Address - Street 1:4001 STINSON BLVD NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-3488
Practice Address - Country:US
Practice Address - Phone:651-367-9613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician