Provider Demographics
NPI:1720951155
Name:WILLIS, PATRICIA RENEE
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:RENEE
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 1:4405 LOGSDONS WOODS DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TWP
Mailing Address - State:OH
Mailing Address - Zip Code:45011-6582
Mailing Address - Country:US
Mailing Address - Phone:615-519-7433
Mailing Address - Fax:
Practice Address - Street 1:7243 EASTLAWN DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45237-3515
Practice Address - Country:US
Practice Address - Phone:513-740-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician