Provider Demographics
NPI:1154615912
Name:WILLIS, SHAVON (MHPP)
Entity type:Individual
Prefix:
First Name:SHAVON
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11818
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1818
Mailing Address - Country:US
Mailing Address - Phone:479-452-6650
Mailing Address - Fax:479-452-5847
Practice Address - Street 1:3906 MORRIS DR
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-6216
Practice Address - Country:US
Practice Address - Phone:479-629-0285
Practice Address - Fax:479-452-5847
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator