Provider Demographics
NPI:1649099300
Name:WILLIS, NYIA (BSW, ADT)
Entity type:Individual
Prefix:
First Name:NYIA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:BSW, ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8409 HOLLOW TREE LN UPPR MARLBORO
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-9621
Mailing Address - Country:US
Mailing Address - Phone:301-316-8230
Mailing Address - Fax:
Practice Address - Street 1:1014 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-4228
Practice Address - Country:US
Practice Address - Phone:240-342-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT3346101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)