Provider Demographics
NPI:1124442561
Name:WILLIS, CHARLOTTE ANN
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:ANN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:ANN
Other - Last Name:WYNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2201 E SURREY LN
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2868
Mailing Address - Country:US
Mailing Address - Phone:580-272-3674
Mailing Address - Fax:
Practice Address - Street 1:2201 E SURREY LN
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2868
Practice Address - Country:US
Practice Address - Phone:580-272-3674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst