Provider Demographics
NPI:1255620746
Name:WILLIS, ROBERT A (MA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1656
Mailing Address - Street 2:
Mailing Address - City:N WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-1656
Mailing Address - Country:US
Mailing Address - Phone:336-838-1644
Mailing Address - Fax:336-667-7720
Practice Address - Street 1:204 JEFFERSON ST
Practice Address - Street 2:SUITE 106
Practice Address - City:N WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3586
Practice Address - Country:US
Practice Address - Phone:336-838-1644
Practice Address - Fax:336-667-7720
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist