MEDICARE: LAURA HALL WILLIS LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH-OOO4171	FL

General Provider Information

NPI Number	:	1639234560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA HALL WILLIS LMHC

Provider Business Mailing Address
First Line	:	PO BOX 92
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32961-0092
Country	:	US
Telephone Number	:	772-567-6370
Fax Number	:	772-567-3307

Provider Business Practice Location Address
First Line	:	1405 21ST ST
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-3490
Country	:	US
Telephone Number	:	772-567-6370
Fax Number	:	772-567-2672

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	07/08/2007

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