Provider Demographics
NPI:1457821878
Name:WILLIS, ZACHARY DYNELL
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:DYNELL
Last Name:WILLIS
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 1:1002 OSWEGO ST, UTICA
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502
Mailing Address - Country:US
Mailing Address - Phone:315-798-8868
Mailing Address - Fax:
Practice Address - Street 1:3580 WILSHIRE BLVD STE 2000
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2533
Practice Address - Country:US
Practice Address - Phone:213-381-1250
Practice Address - Fax:213-383-4803
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral