=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225523780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIS ADVANCED COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2018
-----------------------------------------------------
Last Update Date | 02/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 SUPERIOR ST STE A
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-824-4590
-----------------------------------------------------
Fax | 810-937-5439
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 805 SUPERIOR ST STE A
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-3771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-824-4590
-----------------------------------------------------
Fax | 810-937-5439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DINA CAMPBELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 586-549-8887
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401015730
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------