Provider Demographics
NPI:1619121944
Name:WILLIS, HEATHER NICOLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:NICOLE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 JOEL DR.
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-8262
Mailing Address - Country:US
Mailing Address - Phone:270-798-8437
Mailing Address - Fax:270-412-9527
Practice Address - Street 1:650 JOEL DR.
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-8262
Practice Address - Country:US
Practice Address - Phone:270-798-8437
Practice Address - Fax:270-412-9527
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2815103T00000X
KYKY-129385103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist