Provider Demographics
NPI:1134838436
Name:WILLIS, CHARLYNN ANN (LMHC)
Entity type:Individual
Prefix:MS
First Name:CHARLYNN
Middle Name:ANN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 WELCHER AVE
Mailing Address - Street 2:
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-5638
Mailing Address - Country:US
Mailing Address - Phone:917-558-2169
Mailing Address - Fax:
Practice Address - Street 1:2125 ALBANY POST RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:NY
Practice Address - Zip Code:10548-1447
Practice Address - Country:US
Practice Address - Phone:917-558-2169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY09531-01101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health