Provider Demographics
NPI:1922174101
Name:WILLIS, CHARITY L (LMP)
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:CHARITY
Other - Middle Name:L
Other - Last Name:WILLIS-COUSINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:PO BOX 8051
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-0051
Mailing Address - Country:US
Mailing Address - Phone:509-469-1903
Mailing Address - Fax:509-469-1905
Practice Address - Street 1:611 S 48TH AVE
Practice Address - Street 2:B
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3614
Practice Address - Country:US
Practice Address - Phone:509-952-3455
Practice Address - Fax:509-469-1905
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021144225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0206031OtherWA LABOR & INDUSTRIES