=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538950993
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE VICTORIA WILLIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2025
-----------------------------------------------------
Last Update Date | 05/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 MEMORY LN
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47711-2443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-337-6528
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5100 MEMORY LN
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47711-2443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-337-6528
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 222Q00000X
-----------------------------------------------------
Taxonomy Name | Developmental Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------