Provider Demographics
NPI:1295086841
Name:WILLIS, SANDRA L (MSW)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 CANTERBURY BLVD
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-4913
Mailing Address - Country:US
Mailing Address - Phone:580-477-0156
Mailing Address - Fax:
Practice Address - Street 1:1335 CANTERBURY BLVD
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-4913
Practice Address - Country:US
Practice Address - Phone:580-477-0156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-23
Last Update Date:2012-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4345-P104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker