Provider Demographics
NPI:1831080290
Name:WILLIS, TANISHA JONIQUE (MHC-MP)
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:JONIQUE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MHC-MP
Other - Prefix:
Other - First Name:TANISHA
Other - Middle Name:JONIQUE
Other - Last Name:ARNOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MCH-LP
Mailing Address - Street 1:1000 MILL RD # 1405
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1400
Mailing Address - Country:US
Mailing Address - Phone:516-965-1442
Mailing Address - Fax:
Practice Address - Street 1:66A MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1202
Practice Address - Country:US
Practice Address - Phone:631-730-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
P134431101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health