Healthcare Provider Details

I. General information

NPI: 1073189072
Provider Name (Legal Business Name): MRS. SYDNEY LANE WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MARKET PATH
GEORGETOWN KY
40324-1579
US

IV. Provider business mailing address

7500 SAN FELIPE ST STE 990
HOUSTON TX
77063-1708
US

V. Phone/Fax

Practice location:
  • Phone: 502-632-6241
  • Fax: 502-427-0854
Mailing address:
  • Phone: 281-826-3382
  • Fax: 425-491-7683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: