Provider Demographics
NPI:1770242653
Name:WILLERTZ, MAYA CENCI
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:CENCI
Last Name:WILLERTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 WALWOOD PL
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5043
Mailing Address - Country:US
Mailing Address - Phone:989-859-0472
Mailing Address - Fax:
Practice Address - Street 1:115 ALLEGAN STREET
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MI
Practice Address - Zip Code:49078
Practice Address - Country:US
Practice Address - Phone:844-244-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician