Provider Demographics
NPI:1952579716
Name:WILLIS, SCOTT A (AAS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:WILLIS
Suffix:
Gender:M
Credentials:AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 WASHINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020
Mailing Address - Country:US
Mailing Address - Phone:585-219-4989
Mailing Address - Fax:
Practice Address - Street 1:422 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569-1023
Practice Address - Country:US
Practice Address - Phone:585-786-8133
Practice Address - Fax:585-786-9928
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00740423Medicaid