Provider Demographics
NPI:1871783399
Name:WILLISON, TIM (MFT, CADC)
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:WILLISON
Suffix:
Gender:M
Credentials:MFT, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 B ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-4505
Mailing Address - Country:US
Mailing Address - Phone:530-219-3848
Mailing Address - Fax:530-757-2705
Practice Address - Street 1:228 B ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-4505
Practice Address - Country:US
Practice Address - Phone:530-219-3848
Practice Address - Fax:530-757-2705
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34937106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist