Provider Demographics
NPI:1043747926
Name:WILLIS, D'UNDRA (LICSW)
Entity type:Individual
Prefix:
First Name:D'UNDRA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 MOORE LAKE DR E STE 205D
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-5176
Mailing Address - Country:US
Mailing Address - Phone:612-412-4819
Mailing Address - Fax:651-304-6027
Practice Address - Street 1:1250 MOORE LAKE DR E STE 205D
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-5176
Practice Address - Country:US
Practice Address - Phone:612-412-4819
Practice Address - Fax:651-304-6027
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN236481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN23648OtherMN BOARD OF SW
MNQ577186700819OtherDRIVERS LISCENSE