Provider Demographics
NPI:1831535236
Name:WILLIS, MACEY LAUREN (LMFT #102377)
Entity type:Individual
Prefix:
First Name:MACEY
Middle Name:LAUREN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LMFT #102377
Other - Prefix:
Other - First Name:MACEY
Other - Middle Name:LAUREN
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2512 DOLLAR ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-2152
Mailing Address - Country:US
Mailing Address - Phone:310-981-8651
Mailing Address - Fax:
Practice Address - Street 1:2512 DOLLAR ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-2152
Practice Address - Country:US
Practice Address - Phone:310-981-8651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2021-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
CA102377101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty