Basic Information
| Provider Information | |||||||||
| NPI: | 1619121944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4555 TROUSDALE DR | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372044513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157813000 | ||||||||
| FaxNumber: | 6157818262 | ||||||||
| Practice Location | |||||||||
| Address1: | BLANCHFIELD ARMY COMMUNITY HOSPITAL | ||||||||
| Address2: | 650 JOEL DR | ||||||||
| City: | FT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988388 | ||||||||
| FaxNumber: | 6157818262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2008 | ||||||||
| LastUpdateDate: | 02/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2815 | TN | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 129385 | KY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.