Provider Demographics
NPI:1871395848
Name:WILLIS, LAXAVIA
Entity type:Individual
Prefix:
First Name:LAXAVIA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:LA
Mailing Address - Zip Code:71040-3703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 HOLLY ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:LA
Practice Address - Zip Code:71040-3703
Practice Address - Country:US
Practice Address - Phone:318-607-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator