Provider Demographics
NPI:1528641446
Name:WILLIS, DELLISSA
Entity type:Individual
Prefix:
First Name:DELLISSA
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 1:1880 N CONGRESS AVE APT G408
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-1687
Mailing Address - Country:US
Mailing Address - Phone:561-306-9213
Mailing Address - Fax:
Practice Address - Street 1:6513 LANDINGS CT
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-4078
Practice Address - Country:US
Practice Address - Phone:800-828-5659
Practice Address - Fax:866-857-0246
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician