Healthcare Provider Details

I. General information

NPI: 1437302130
Provider Name (Legal Business Name): ERIC LEE WILLMS PSY.D., LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 EAST SECOND STREET
DULUTH MN
55805
US

IV. Provider business mailing address

530 EAST SECOND STREET
DULUTH MN
55805
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-5360
  • Fax: 218-727-1167
Mailing address:
  • Phone: 218-786-5360
  • Fax: 218-727-1167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180005328
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180005328
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180005328
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5756
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: