Healthcare Provider Details

I. General information

NPI: 1073148169
Provider Name (Legal Business Name): KYSON WILLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7191 WAGNER WAY STE 304
GIG HARBOR WA
98335-6909
US

IV. Provider business mailing address

7191 WAGNER WAY STE 304
GIG HARBOR WA
98335-6909
US

V. Phone/Fax

Practice location:
  • Phone: 253-468-7899
  • Fax:
Mailing address:
  • Phone: 253-468-7899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW61628920
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: