Healthcare Provider Details

I. General information

NPI: 1124130679
Provider Name (Legal Business Name): SCOTT E. WILLI LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1181 RAMSEY AVE
GRANTS PASS OR
97527-5821
US

IV. Provider business mailing address

1215 SW G ST
GRANTS PASS OR
97526-2544
US

V. Phone/Fax

Practice location:
  • Phone: 541-476-2373
  • Fax: 541-476-1526
Mailing address:
  • Phone: 541-476-2373
  • Fax: 541-476-1526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL0755
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier096818
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: