Healthcare Provider Details

I. General information

NPI: 1720212988
Provider Name (Legal Business Name): MELISSA ANTOINETTE WILLIS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 INGRAHAM ST NW
WASHINGTON DC
20011-2904
US

IV. Provider business mailing address

800 INGRAHAM ST NW
WASHINGTON DC
20011-2904
US

V. Phone/Fax

Practice location:
  • Phone: 202-576-6202
  • Fax: 202-576-6205
Mailing address:
  • Phone: 202-576-6202
  • Fax: 202-576-6205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberLC50079341
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: