Provider Demographics
NPI:1063520708
Name:O'MAHEN WILLIS, HEATHER A (PHD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:O'MAHEN WILLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:A
Other - Last Name:O'MAHEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:5331 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9520
Mailing Address - Country:US
Mailing Address - Phone:734-996-9111
Mailing Address - Fax:734-996-1950
Practice Address - Street 1:5331 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9520
Practice Address - Country:US
Practice Address - Phone:734-996-9111
Practice Address - Fax:734-996-1950
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012336101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health