Provider Demographics
NPI:1598364788
Name:WILLIS, PAYTON
Entity type:Individual
Prefix:
First Name:PAYTON
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 1:545 N DEARBORN ST APT 1606
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-5833
Mailing Address - Country:US
Mailing Address - Phone:303-808-7785
Mailing Address - Fax:
Practice Address - Street 1:25 E WASHINGTON ST STE 1835
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1836
Practice Address - Country:US
Practice Address - Phone:312-940-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.017150101YP2500X
IL180.016069101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional