Provider Demographics
NPI:1972327120
Name:WILLIS, ANTHONY K (PSS)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:K
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 HONEYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-4041
Mailing Address - Country:US
Mailing Address - Phone:910-391-0608
Mailing Address - Fax:
Practice Address - Street 1:2001 CATHERINE SIMMONS AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-4677
Practice Address - Country:US
Practice Address - Phone:704-492-1533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2024-12086-01405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional