1770712416 NPI number — KERRA WILLS LCSW

Table of content: KERRA WILLS LCSW (NPI 1770712416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770712416 NPI number — KERRA WILLS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLS
Provider First Name:
KERRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770712416
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1931 WELBY WAY
Provider Second Line Business Mailing Address:
STE 4
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32308-4462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-999-2140
Provider Business Mailing Address Fax Number:
850-270-6572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1931 WELBY WAY
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32308-4462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-999-2140
Provider Business Practice Location Address Fax Number:
850-270-6572
Provider Enumeration Date:
07/02/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW 9292 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: IB002A , issued by the state of ( FL ) . This identifiers is of the category "MEDICARE PIN".
  • Identifier: 001005100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".