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General NPI Number Information
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NPI Number | 1548579121
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Entity Type | Organization
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Legal Business Name | WILLIS CENTER
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Dates
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Enumeration Date | 09/30/2010
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Last Update Date | 09/30/2010
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Provider Practice Location Address
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Address Line | 44 FRONT ST FOURTH FLOOR
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City | WORCESTER
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State | MA
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Zip | 01608-1733
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Country | US
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Telephone | 508-799-2934
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Fax |
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Provider Business Mailing Address
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Address Line | 91 KENBERMA ROAD APARTMENT #2
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City | WORCESTER
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State | MA
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Zip | 01604
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Country | US
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Telephone | 508-479-9310
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Fax |
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Authorized Official
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Title or Position | CLINICIAN
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Name | MS. LISA ANNE SANSOUCY
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Credential | MA CAGS LMHC
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Telephone | 508-799-2934
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 6707
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License Number State | MA
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