Provider Demographics
NPI:1649224742
Name:WILLIS, BETTE ELLEN (LCSW)
Entity type:Individual
Prefix:MS
First Name:BETTE
Middle Name:ELLEN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3814 APPLETON WAY
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-7304
Mailing Address - Country:US
Mailing Address - Phone:910-791-7447
Mailing Address - Fax:
Practice Address - Street 1:108 N KERR AVE
Practice Address - Street 2:SUITE B-1
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3472
Practice Address - Country:US
Practice Address - Phone:910-620-7227
Practice Address - Fax:866-771-7963
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0047141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003086Medicaid
NC138NNOtherBCBS M H PROVIDER
NC6003086Medicaid