Provider Demographics
NPI:1912321415
Name:WILLIS, JANICE (LAC, LCSW-C)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LAC, LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27211 CHIPMANS LN
Mailing Address - Street 2:
Mailing Address - City:FEDERALSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21632-2160
Mailing Address - Country:US
Mailing Address - Phone:410-310-5584
Mailing Address - Fax:
Practice Address - Street 1:8737 BROOKS DR STE 103
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-7474
Practice Address - Country:US
Practice Address - Phone:410-310-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD102671041C0700X
MDU02128171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical