Provider Demographics
NPI:1255428041
Name:WILLS, ROGER LEWIS
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:LEWIS
Last Name:WILLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 SCHATTIG LN
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-7815
Mailing Address - Country:US
Mailing Address - Phone:360-675-1232
Mailing Address - Fax:
Practice Address - Street 1:1100 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4209
Practice Address - Country:US
Practice Address - Phone:360-419-3500
Practice Address - Fax:360-419-3505
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00036980101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health