Healthcare Provider Details

I. General information

NPI: 1801290051
Provider Name (Legal Business Name): IFEANYI C WILLSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 W APACHE TRL STE B109
APACHE JUNCTION AZ
85120-3425
US

IV. Provider business mailing address

PO BOX 746093
ATLANTA GA
30374-6093
US

V. Phone/Fax

Practice location:
  • Phone: 480-618-0945
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-15631
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: