Basic Information
| Provider Information | |||||||||
| NPI: | 1316256761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLETS | ||||||||
| FirstName: | WILL | ||||||||
| MiddleName: | MERYL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 781 E WEBER RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432111048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193041514 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3645 RIDGE MILL DR | ||||||||
| Address2: | |||||||||
| City: | HILLIARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430267752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144577876 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2010 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1200640 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 2846675 | 05 | OH | MEDICAID |