Provider Demographics
NPI:1073189072
Name:WILLIS, SYDNEY LANE
Entity type:Individual
Prefix:MRS
First Name:SYDNEY
Middle Name:LANE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 SAN FELIPE ST STE 990
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-1708
Mailing Address - Country:US
Mailing Address - Phone:281-826-3382
Mailing Address - Fax:425-491-7683
Practice Address - Street 1:104 MARKET PATH
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1579
Practice Address - Country:US
Practice Address - Phone:502-632-6241
Practice Address - Fax:502-427-0854
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
KY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician