Healthcare Provider Details

I. General information

NPI: 1316954662
Provider Name (Legal Business Name): DALE WAYNE WILLIS MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W CHESAPEAKE AVE STE 300
TOWSON MD
21204-4440
US

IV. Provider business mailing address

143 LONG DR
ELKTON MD
21921-3691
US

V. Phone/Fax

Practice location:
  • Phone: 410-828-6619
  • Fax:
Mailing address:
  • Phone: 410-392-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06770
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: