Provider Demographics
NPI:1437048816
Name:WILLIS, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2737 PIN OAK DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-1862
Mailing Address - Country:US
Mailing Address - Phone:419-318-9350
Mailing Address - Fax:
Practice Address - Street 1:3454 OAK ALLEY CT STE 305
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1365
Practice Address - Country:US
Practice Address - Phone:567-318-1552
Practice Address - Fax:567-429-0185
Is Sole Proprietor?:No
Enumeration Date:2025-07-01
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1904499104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker