MEDICARE: PRISCILLA ANNE WILLMOTT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	12762	CA

General Provider Information

NPI Number	:	1598272858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRISCILLA ANNE WILLMOTT

Provider Business Mailing Address
First Line	:	12139 MOUNT VERNON AVE STE 202
Second Line	:
City	:	GRAND TERRACE
State	:	CA
Zip	:	92313-5547
Country	:	US
Telephone Number	:	909-323-3505
Fax Number	:

Provider Business Practice Location Address
First Line	:	12139 MOUNT VERNON AVE STE 202
Second Line	:
City	:	GRAND TERRACE
State	:	CA
Zip	:	92313-5547
Country	:	US
Telephone Number	:	909-323-3505
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2018
Last Update Date	:	06/13/2023

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