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General NPI Number Information
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NPI Number | 1063795870
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Entity Type | Organization
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Legal Business Name | WILL'S WAY, LLC
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Dates
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Enumeration Date | 09/28/2011
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Last Update Date | 09/28/2011
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Provider Practice Location Address
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Address Line | 604 ADELINE ST SUITE B
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City | HATTIESBURG
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State | MS
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Zip | 39401-3842
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Country | US
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Telephone | 601-466-9190
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Fax | 186-662-5055
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Provider Business Mailing Address
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Address Line | PO BOX 15955
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City | HATTIESBURG
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State | MS
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Zip | 39404-5955
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Country | US
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Telephone | 601-466-9190
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Fax | 186-662-5055
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Authorized Official
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Title or Position | CO-OWNER PROGRAM DIRECTOR
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Name | DR. DANNELL SPEIGHTS ROBERTS
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Credential | PH.D.
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Telephone | 601-466-9190
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 204130
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 47821
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License Number State | MS
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