Healthcare Provider Details

I. General information

NPI: 1740603570
Provider Name (Legal Business Name): MRS. BEVERLY WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2014
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9367 TWO NOTCH RD SUITE C2
COLUMBIA SC
29223-6442
US

IV. Provider business mailing address

9367 TWO NOTCH RD SUITE C2
COLUMBIA SC
29223-6442
US

V. Phone/Fax

Practice location:
  • Phone: 404-956-2691
  • Fax: 803-661-1093
Mailing address:
  • Phone: 404-956-2691
  • Fax: 803-661-1093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: