MEDICARE: MS. BRENDA L WILLIS LCSW

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	1041C0700X	Clinical Social Worker	2005015072	MO
2	1041C0700X	Clinical Social Worker	077648	NY

General Provider Information

NPI Number	:	1790989978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BRENDA L WILLIS LCSW

Provider Business Mailing Address
First Line	:	1841 25TH RD
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11102-3427
Country	:	US
Telephone Number	:	816-213-9775
Fax Number	:

Provider Business Practice Location Address
First Line	:	1332 SURF AVENUE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11224
Country	:	US
Telephone Number	:	718-449-4000
Fax Number	:	718-449-5146

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

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	09/30/2010

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