Provider Demographics
NPI:1184354672
Name:WILLIS, BENJAMIN SHEPPARD (LCSW-A)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:SHEPPARD
Last Name:WILLIS
Suffix:
Gender:M
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 UNIVERSITY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-6260
Mailing Address - Country:US
Mailing Address - Phone:919-433-0170
Mailing Address - Fax:919-226-0026
Practice Address - Street 1:3608 UNIVERSITY DR STE 101
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6260
Practice Address - Country:US
Practice Address - Phone:919-433-0170
Practice Address - Fax:919-226-0026
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0158471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical