Provider Demographics
NPI:1528451234
Name:WILLIS, HAROLD
Entity type:Individual
Prefix:
First Name:HAROLD
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
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 3211
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76099-3211
Mailing Address - Country:US
Mailing Address - Phone:682-622-6013
Mailing Address - Fax:
Practice Address - Street 1:2304 BARDIN RD
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3850
Practice Address - Country:US
Practice Address - Phone:682-622-6013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9398101YA0400X
TX73141101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)