Provider Demographics
NPI:1902892003
Name:WILLIS, VIRGINIA GAIL (LCSW)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:GAIL
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 ASPEN
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274
Mailing Address - Country:US
Mailing Address - Phone:562-866-1895
Mailing Address - Fax:562-866-5730
Practice Address - Street 1:25500 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CO
Practice Address - Zip Code:90505
Practice Address - Country:US
Practice Address - Phone:310-378-0920
Practice Address - Fax:562-866-5730
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS20227104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
P99403Medicare UPIN
CASW20227Medicare ID - Type Unspecified