Provider Demographics
NPI:1104279785
Name:WILLIS, KIMBERLY RENEE (MED, LPC, LCDC)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:RENEE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MED, LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12307 GRANITE WOODS CT
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-3276
Mailing Address - Country:US
Mailing Address - Phone:281-789-6734
Mailing Address - Fax:713-564-0767
Practice Address - Street 1:12307 GRANITE WOODS CT
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-3276
Practice Address - Country:US
Practice Address - Phone:281-789-6734
Practice Address - Fax:713-564-0767
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70709101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional