=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437403292
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER L WILLIS MA LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2012
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16001 W 9 MILE RD PROVIDENCE HOSPITAL
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-4818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-849-2096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22195 WESTHAMPTON ST
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48237-3805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 6401008989
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------