Provider Demographics
NPI:1295504298
Name:WILLIS-WILDMAN, ZOE ANN
Entity type:Individual
Prefix:
First Name:ZOE
Middle Name:ANN
Last Name:WILLIS-WILDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 E WOODMEN RD APT 66
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3385
Mailing Address - Country:US
Mailing Address - Phone:916-296-1998
Mailing Address - Fax:
Practice Address - Street 1:1706 N CIRCLE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-2409
Practice Address - Country:US
Practice Address - Phone:719-354-5297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-23-319026106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician