Healthcare Provider Details

I. General information

NPI: 1003634940
Provider Name (Legal Business Name): DENISE WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 ERTEN ST
THOUSAND OAKS CA
91360-1810
US

IV. Provider business mailing address

4346 CAMINO DE LA ROSA
NEWBURY PARK CA
91320-6716
US

V. Phone/Fax

Practice location:
  • Phone: 805-300-7084
  • Fax:
Mailing address:
  • Phone: 805-300-7084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: