Provider Demographics
NPI:1124767157
Name:WILLIS, ELISSA (LSW)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 DICK AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44302-1015
Mailing Address - Country:US
Mailing Address - Phone:234-788-1373
Mailing Address - Fax:
Practice Address - Street 1:275 MARTINEL DR
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4380
Practice Address - Country:US
Practice Address - Phone:234-788-1373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-27
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2207677104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker