Provider Demographics
NPI:1174619183
Name:WILLARD, ANN (MS,CCCA)
Entity type:Individual
Prefix:MRS
First Name:ANN
Middle Name:
Last Name:WILLARD
Suffix:
Gender:F
Credentials:MS,CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 DONNALLY ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1648
Mailing Address - Country:US
Mailing Address - Phone:304-342-0124
Mailing Address - Fax:304-340-2204
Practice Address - Street 1:500 DONNALLY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1648
Practice Address - Country:US
Practice Address - Phone:304-342-0124
Practice Address - Fax:304-340-2204
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA0193231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810025124Medicaid
WVA0193OtherSTATE LICENSE