Provider Demographics
NPI:1720160146
Name:WILLIS, CHARLES STEPHEN (MMFT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:STEPHEN
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3711
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79604-3711
Mailing Address - Country:US
Mailing Address - Phone:325-437-1001
Mailing Address - Fax:325-437-1005
Practice Address - Street 1:500 CHESTNUT ST
Practice Address - Street 2:STE. 1001
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79602-1453
Practice Address - Country:US
Practice Address - Phone:325-437-1001
Practice Address - Fax:325-437-1005
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1800106H00000X
TX9937101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2617LCOtherBLUECROSS/BLUESHIELD
TX0262651-01Medicaid