Provider Demographics
NPI:1962972679
Name:WILLSEY, AUDRA MARY (LCSW)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:MARY
Last Name:WILLSEY
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 1:3504 ROCK OAK TRL
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-7926
Mailing Address - Country:US
Mailing Address - Phone:321-287-8567
Mailing Address - Fax:
Practice Address - Street 1:3504 ROCK OAK TRL
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32141-7926
Practice Address - Country:US
Practice Address - Phone:321-287-8567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW91021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical