Provider Demographics
NPI:1013507367
Name:WILLIS, TONI (MA-CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TONI
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MA-CCC-SLP
Other - Prefix:MISS
Other - First Name:TONI
Other - Middle Name:
Other - Last Name:MEDURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA-CCC-SLP
Mailing Address - Street 1:777 GOGUAC ST W STE B2
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49015-2097
Mailing Address - Country:US
Mailing Address - Phone:269-223-7786
Mailing Address - Fax:
Practice Address - Street 1:777 GOGUAC ST W STE B2
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MI
Practice Address - Zip Code:49015-2097
Practice Address - Country:US
Practice Address - Phone:269-223-7786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0000000000Medicaid