Provider Demographics
NPI:1710719893
Name:WILLIS, AMARRI
Entity type:Individual
Prefix:
First Name:AMARRI
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 N RIVERSIDE AVE APT 113
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-8002
Mailing Address - Country:US
Mailing Address - Phone:909-571-2627
Mailing Address - Fax:
Practice Address - Street 1:165 W HOSPITALITY LN STE 27
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3326
Practice Address - Country:US
Practice Address - Phone:442-327-9172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician