Provider Demographics
NPI:1407467392
Name:WILLIS, TYLER DREW (LCSW)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:DREW
Last Name:WILLIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2875 W RAY ROAD
Mailing Address - Street 2:SUITE 6-430-10080
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224
Mailing Address - Country:US
Mailing Address - Phone:858-224-2692
Mailing Address - Fax:
Practice Address - Street 1:2875 W RAY ROAD
Practice Address - Street 2:SUITE 6-430-10080
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224
Practice Address - Country:US
Practice Address - Phone:858-224-2692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical