Healthcare Provider Details

I. General information

NPI: 1225523780
Provider Name (Legal Business Name): WILLIS ADVANCED COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 SUPERIOR ST STE A
PORT HURON MI
48060
US

IV. Provider business mailing address

805 SUPERIOR ST STE A
PORT HURON MI
48060-3771
US

V. Phone/Fax

Practice location:
  • Phone: 810-824-4590
  • Fax: 810-937-5439
Mailing address:
  • Phone: 810-824-4590
  • Fax: 810-937-5439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401015730
License Number StateMI

VIII. Authorized Official

Name: DINA CAMPBELL
Title or Position: OWNER
Credential:
Phone: 586-549-8887