Provider Demographics
NPI:1952808610
Name:WILLIS, SONYA DELAINE
Entity Type:Individual
Prefix:MS
First Name:SONYA
Middle Name:DELAINE
Last Name:WILLIS
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 1:22710 LAWNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-2539
Mailing Address - Country:US
Mailing Address - Phone:170-857-4110
Mailing Address - Fax:
Practice Address - Street 1:1473 RING RD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5459
Practice Address - Country:US
Practice Address - Phone:708-862-8156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178013816101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health