Provider Demographics
NPI:1043765290
Name:WILLIS, ANDREL (LMT, ESTHETICIAN)
Entity type:Individual
Prefix:
First Name:ANDREL
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LMT, ESTHETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:362 WILSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-1514
Mailing Address - Country:US
Mailing Address - Phone:815-630-8312
Mailing Address - Fax:
Practice Address - Street 1:351 W CHICAGO AVE STE 6
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-5125
Practice Address - Country:US
Practice Address - Phone:630-360-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2023-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227017963225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist