Provider Demographics
NPI:1740470814
Name:WILLIS, KIM (MFT)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COCONUT GROVE LN
Mailing Address - Street 2:
Mailing Address - City:LAHAINA
Mailing Address - State:HI
Mailing Address - Zip Code:96761-8735
Mailing Address - Country:US
Mailing Address - Phone:808-669-6867
Mailing Address - Fax:808-669-7787
Practice Address - Street 1:10 COCONUT GROVE LN
Practice Address - Street 2:
Practice Address - City:LAHAINA
Practice Address - State:HI
Practice Address - Zip Code:96761-8735
Practice Address - Country:US
Practice Address - Phone:808-669-6867
Practice Address - Fax:808-669-7787
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI77106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist