Provider Demographics
NPI:1750337721
Name:WILLIS, PAMELA YVETTE (LCSW-C)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:YVETTE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3930 NEMO RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4041
Mailing Address - Country:US
Mailing Address - Phone:443-804-3707
Mailing Address - Fax:410-521-1944
Practice Address - Street 1:5310 OLD COURT RD
Practice Address - Street 2:STE. 308
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5243
Practice Address - Country:US
Practice Address - Phone:443-804-3707
Practice Address - Fax:410-521-1944
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD097161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404403700Medicaid