Provider Demographics
NPI:1699950089
Name:WILLIS, ANGELA KAY (MSW, LISW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:KAY
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:KAY
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35159 BURKHART RD
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43713-9796
Mailing Address - Country:US
Mailing Address - Phone:740-425-2834
Mailing Address - Fax:
Practice Address - Street 1:244 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43713-1323
Practice Address - Country:US
Practice Address - Phone:740-238-0628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00943050104100000X
OHI 10003071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV002009594OtherBCBS