Provider Demographics
NPI:1316954662
Name:WILLIS, DALE WAYNE (MSW)
Entity type:Individual
Prefix:MR
First Name:DALE
Middle Name:WAYNE
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 LONG DR
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-3691
Mailing Address - Country:US
Mailing Address - Phone:410-392-3171
Mailing Address - Fax:
Practice Address - Street 1:305 W CHESAPEAKE AVE STE 300
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4440
Practice Address - Country:US
Practice Address - Phone:410-828-6619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD067701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical