MEDICARE: RICHARD WILLIS M.A./LPA

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	103T00000X	Psychologist	797	NC

General Provider Information

NPI Number	:	1598878688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD WILLIS M.A./LPA

Provider Business Mailing Address
First Line	:	3015 CHINA BERRY CT
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28104-4314
Country	:	US
Telephone Number	:	704-534-6014
Fax Number	:

Provider Business Practice Location Address
First Line	:	3015 CHINA BERRY CT
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28104-4314
Country	:	US
Telephone Number	:	704-534-6014
Fax Number	:

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

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	07/08/2007

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