Provider Demographics
NPI:1285721233
Name:WILLIS, CYNTHIA (MED, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MED, CCC-SLP
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 40786
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27629-0786
Mailing Address - Country:US
Mailing Address - Phone:919-946-9787
Mailing Address - Fax:866-294-8582
Practice Address - Street 1:3948 BROWNING PL STE 329
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6512
Practice Address - Country:US
Practice Address - Phone:919-946-9787
Practice Address - Fax:866-294-8582
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6440235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412303Medicaid