Provider Demographics
NPI:1083162689
Name:WILLIS, LILIA CARREON
Entity type:Individual
Prefix:
First Name:LILIA
Middle Name:CARREON
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LILIA
Other - Middle Name:
Other - Last Name:KINKEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PPS
Mailing Address - Street 1:2090 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-5416
Mailing Address - Country:US
Mailing Address - Phone:909-593-8397
Mailing Address - Fax:
Practice Address - Street 1:2090 WALNUT ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-5416
Practice Address - Country:US
Practice Address - Phone:909-593-8397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool