Provider Demographics
NPI:1336708833
Name:WILLIS, CHRISTINE L (MSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4527 N 16TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5353
Mailing Address - Country:US
Mailing Address - Phone:602-845-8000
Mailing Address - Fax:602-845-8001
Practice Address - Street 1:4527 N 16TH ST STE 104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5353
Practice Address - Country:US
Practice Address - Phone:602-845-8000
Practice Address - Fax:602-845-8001
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW17675104100000X
AZ176751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker