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General NPI Number Information
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NPI Number | 1619121944
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Entity Type | Individual
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Provider Name | HEATHER NICOLE WILLIS PSY.D.
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Gender | Female
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Dates
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Enumeration Date | 11/13/2008
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Last Update Date | 04/08/2025
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Provider Practice Location Address
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Address Line | 650 JOEL DR.
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City | FORT CAMPBELL
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State | KY
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Zip | 42223-8262
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Country | US
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Telephone | 270-798-8437
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Fax | 270-412-9527
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Provider Business Mailing Address
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Address Line | 650 JOEL DR.
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City | FORT CAMPBELL
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State | KY
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Zip | 42223-8262
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Country | US
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Telephone | 270-798-8437
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Fax | 270-412-9527
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2815
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | KY-129385
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License Number State | KY
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