Provider Demographics
NPI:1356801856
Name:WILLIS, PATRICIA ANN (QMHP)
Entity type:Individual
Prefix:MISS
First Name:PATRICIA
Middle Name:ANN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 LINCOLN MALL DR
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-3811
Mailing Address - Country:US
Mailing Address - Phone:708-747-2655
Mailing Address - Fax:
Practice Address - Street 1:4747 LINCOLN MALL DR
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-3811
Practice Address - Country:US
Practice Address - Phone:706-747-2655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health