Healthcare Provider Details

I. General information

NPI: 1568563781
Provider Name (Legal Business Name): MAX HUGH WILLIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7744 BROADWAY SUITE 105
SAN ANTONIO TX
78209
US

IV. Provider business mailing address

7744 BROADWAY SUITE 105
SAN ANTONIO TX
78209
US

V. Phone/Fax

Practice location:
  • Phone: 210-822-3966
  • Fax: 210-822-7542
Mailing address:
  • Phone: 210-822-3966
  • Fax: 210-822-7542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2-2717
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: