Provider Demographics
NPI:1942969811
Name:WILLIS, KRYSTAL ANGELA (MMPA)
Entity type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:ANGELA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MMPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 N HENDERSON RD
Mailing Address - Street 2:PLAZA SUITES 7&8
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203
Mailing Address - Country:US
Mailing Address - Phone:571-777-9210
Mailing Address - Fax:
Practice Address - Street 1:4141 N HENDERSON RD
Practice Address - Street 2:PLAZA SUITES 7&8
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203
Practice Address - Country:US
Practice Address - Phone:571-777-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician