Basic Information
| Provider Information | |||||||||
| NPI: | 1306357298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9325 MIDLOTHIAN TPKE STE A | ||||||||
| Address2: | |||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232354943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574903223 | ||||||||
| FaxNumber: | 7574902936 | ||||||||
| Practice Location | |||||||||
| Address1: | 9325 MIDLOTHIAN TPKE STE A | ||||||||
| Address2: | |||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232354943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574903223 | ||||||||
| FaxNumber: | 7574902936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2017 | ||||||||
| LastUpdateDate: | 10/18/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2202008538 | VA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.