Healthcare Provider Details

I. General information

NPI: 1457821878
Provider Name (Legal Business Name): ZACHARY DYNELL WILLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 10/16/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3580 WILSHIRE BLVD STE 2000
LOS ANGELES CA
90010-2533
US

IV. Provider business mailing address

1002 OSWEGO ST, UTICA
UTICA NY
13502
US

V. Phone/Fax

Practice location:
  • Phone: 213-381-1250
  • Fax: 213-383-4803
Mailing address:
  • Phone: 315-798-8868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: