Provider Demographics
NPI:1629185327
Name:WILLIS, STEVEN JERROLD (MED)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:JERROLD
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 12TH STREET
Mailing Address - Street 2:SUITE 204
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-3011
Mailing Address - Country:US
Mailing Address - Phone:305-747-2124
Mailing Address - Fax:305-293-4339
Practice Address - Street 1:1111 12TH STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-3011
Practice Address - Country:US
Practice Address - Phone:305-747-2124
Practice Address - Fax:305-293-4339
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMHC 6306101YP2500X
FLMFT 2056106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMFT 2056Medicare ID - Type UnspecifiedLMFT
GAMHC 6306Medicare ID - Type UnspecifiedLMHC