Provider Demographics
NPI:1962748129
Name:WILLIS, KANISHA NICOLE
Entity type:Individual
Prefix:MRS
First Name:KANISHA
Middle Name:NICOLE
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 1:1700 EVERGLADE CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73128-7002
Mailing Address - Country:US
Mailing Address - Phone:405-301-5516
Mailing Address - Fax:
Practice Address - Street 1:1700 EVERGLADE CT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73128-7002
Practice Address - Country:US
Practice Address - Phone:405-301-5516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-17
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional