Healthcare Provider Details

I. General information

NPI: 1871620583
Provider Name (Legal Business Name): PATRICIA ANN WILLIS M.A.,LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43740 N GROESBECK HWY
CLINTON TWP MI
48036-1139
US

IV. Provider business mailing address

4210 LAKEWOOD DR
WATERFORD MI
48329-3849
US

V. Phone/Fax

Practice location:
  • Phone: 586-469-7802
  • Fax: 586-469-7662
Mailing address:
  • Phone: 248-797-8259
  • Fax: 586-469-7662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number6301010461
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: