Provider Demographics
NPI:1982470266
Name:WILLIS, MONDERRICK
Entity Type:Individual
Prefix:
First Name:MONDERRICK
Middle Name:
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 1:394 BROADWAY FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-6023
Mailing Address - Country:US
Mailing Address - Phone:718-514-6007
Mailing Address - Fax:
Practice Address - Street 1:394 BROADWAY FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-6023
Practice Address - Country:US
Practice Address - Phone:718-516-6007
Practice Address - Fax:212-584-5450
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY39117101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)