Healthcare Provider Details

I. General information

NPI: 1043174881
Provider Name (Legal Business Name): BARRY WILLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 SW 43RD ST STE 140
RENTON WA
98057-4803
US

IV. Provider business mailing address

1412 SW 43RD ST STE 140
RENTON WA
98057-4803
US

V. Phone/Fax

Practice location:
  • Phone: 425-264-0750
  • Fax:
Mailing address:
  • Phone: 425-264-0750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDPT.CO.70033973
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: