Healthcare Provider Details

I. General information

NPI: 1093178246
Provider Name (Legal Business Name): HEATHER LEE WILLIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 ATASCADERO RD
MORRO BAY CA
93442-1516
US

IV. Provider business mailing address

1500 LIZZIE ST
SAN LUIS OBISPO CA
93401-3062
US

V. Phone/Fax

Practice location:
  • Phone: 805-771-1845
  • Fax:
Mailing address:
  • Phone: 805-549-1200
  • Fax: 661-868-8834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW69338
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW104186
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: