Provider Demographics
NPI:1447648449
Name:WILLIS, TERRIE ANN (BA)
Entity type:Individual
Prefix:MRS
First Name:TERRIE
Middle Name:ANN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 S CHESLEY DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-4904
Mailing Address - Country:US
Mailing Address - Phone:502-773-5459
Mailing Address - Fax:
Practice Address - Street 1:1120 S CHESLEY DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-4904
Practice Address - Country:US
Practice Address - Phone:502-773-5459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator