Provider Demographics
NPI:1164095246
Name:WILLIS, HEATHER EILEEN (LCSW)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:EILEEN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3171 S 129TH EAST AVE # 3037
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74134-3205
Mailing Address - Country:US
Mailing Address - Phone:918-500-2351
Mailing Address - Fax:918-380-3004
Practice Address - Street 1:3171 S 129TH EAST AVE # 3037
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74134-3205
Practice Address - Country:US
Practice Address - Phone:918-500-2351
Practice Address - Fax:918-380-3004
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2025-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10802804-03104100000X
OK205801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200999130AMedicaid