Healthcare Provider Details

I. General information

NPI: 1245874049
Provider Name (Legal Business Name): CHANEE A WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHANEE RUDOLPH

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 BLADENSBURG RD NE
WASHINGTON DC
20018-1440
US

IV. Provider business mailing address

4 ATLANTIC ST SW
WASHINGTON DC
20032-2350
US

V. Phone/Fax

Practice location:
  • Phone: 202-470-3080
  • Fax: 202-232-8494
Mailing address:
  • Phone: 202-470-3080
  • Fax: 202-232-8494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT200001455
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3251
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: