MEDICARE: MRS. BEVERLY WILLIS

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	101Y00000X	Counselor
2	101YP1600X	Pastoral Counselor

General Provider Information

NPI Number	:	1740603570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BEVERLY WILLIS

Provider Business Mailing Address
First Line	:	9367 TWO NOTCH RD
Second Line	:	SUITE C2
City	:	COLUMBIA
State	:	SC
Zip	:	29223-6442
Country	:	US
Telephone Number	:	404-956-2691
Fax Number	:	803-661-1093

Provider Business Practice Location Address
First Line	:	9367 TWO NOTCH RD
Second Line	:	SUITE C2
City	:	COLUMBIA
State	:	SC
Zip	:	29223-6442
Country	:	US
Telephone Number	:	404-956-2691
Fax Number	:	803-661-1093

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

Provider Enumeration Date	:	01/30/2014
Last Update Date	:	01/30/2014

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