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General NPI Number Information
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NPI Number | 1043747926
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Entity Type | Individual
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Provider Name | D'UNDRA WILLIS LICSW
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Gender | Female
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Dates
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Enumeration Date | 05/22/2017
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Last Update Date | 11/22/2024
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Provider Practice Location Address
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Address Line | 1250 MOORE LAKE DR E STE 205D
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City | FRIDLEY
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State | MN
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Zip | 55432-5176
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Country | US
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Telephone | 612-412-4819
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Fax | 651-304-6027
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Provider Business Mailing Address
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Address Line | 1250 MOORE LAKE DR E STE 205D
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City | FRIDLEY
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State | MN
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Zip | 55432-5176
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Country | US
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Telephone | 612-412-4819
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Fax | 651-304-6027
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 23648
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License Number State | MN
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