Provider Demographics
NPI:1699259507
Name:WILLIS, CHARLES DERRELL
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DERRELL
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 1:1518 N SERRANO AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-4874
Mailing Address - Country:US
Mailing Address - Phone:323-536-7817
Mailing Address - Fax:
Practice Address - Street 1:5650 JILLSON ST
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-1482
Practice Address - Country:US
Practice Address - Phone:323-201-4516
Practice Address - Fax:323-215-0170
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health