Provider Demographics
NPI:1306477658
Name:WASHBURN WILLIS, MINDY (CDCA2)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:WASHBURN WILLIS
Suffix:
Gender:F
Credentials:CDCA2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9403 KENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6895
Mailing Address - Country:US
Mailing Address - Phone:330-687-4731
Mailing Address - Fax:
Practice Address - Street 1:519 XENIA AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-1823
Practice Address - Country:US
Practice Address - Phone:937-369-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA171634101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)