Provider Demographics
NPI:1568848562
Name:WILLIS, CASSIE
Entity type:Individual
Prefix:
First Name:CASSIE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 LEA ST
Mailing Address - Street 2:
Mailing Address - City:PAMPA
Mailing Address - State:TX
Mailing Address - Zip Code:79065-3228
Mailing Address - Country:US
Mailing Address - Phone:806-440-2978
Mailing Address - Fax:806-358-4345
Practice Address - Street 1:2104 LEA ST
Practice Address - Street 2:
Practice Address - City:PAMPA
Practice Address - State:TX
Practice Address - Zip Code:79065-3228
Practice Address - Country:US
Practice Address - Phone:806-440-2978
Practice Address - Fax:806-358-4345
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70645101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional