Provider Demographics
NPI:1881940302
Name:WILLIS, KWIN LESLIE
Entity type:Individual
Prefix:
First Name:KWIN
Middle Name:LESLIE
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 EAST 1090 SOUTH
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44 N HIGHWAY 91 STE 1
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:UT
Practice Address - Zip Code:84333-1419
Practice Address - Country:US
Practice Address - Phone:435-535-5784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9578164-3902106H00000X, 106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program