Provider Demographics
NPI:1013477462
Name:WILLIS, ANGELINE DOMINIQUE
Entity Type:Individual
Prefix:
First Name:ANGELINE
Middle Name:DOMINIQUE
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 1:30323 S BRUCE TOMLIN ST
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-7624
Mailing Address - Country:US
Mailing Address - Phone:503-654-3400
Mailing Address - Fax:
Practice Address - Street 1:821 SAGINAW ST S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4121
Practice Address - Country:US
Practice Address - Phone:503-315-8646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health