Provider Demographics
NPI:1043308349
Name:WILLS, LORI MARIE (PHD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:MARIE
Last Name:WILLS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4833 DARROW RD STE 100
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-1411
Mailing Address - Country:US
Mailing Address - Phone:330-422-3255
Mailing Address - Fax:330-422-3256
Practice Address - Street 1:4833 DARROW RD STE 100
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-1411
Practice Address - Country:US
Practice Address - Phone:330-422-3255
Practice Address - Fax:330-422-3256
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5012103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0171488Medicaid
OHW1CP17681Medicare ID - Type Unspecified
OH0171488Medicaid