Individual
MISS KATHY RENEE WILLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
11026 E SEGURA AVE, MESA, AZ 85212-5214
(480) 235-9107
Mailing address
11026 E SEGURA AVE, MESA, AZ 85212-5214
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
3162012
AZ
385HR2055X
Child Mental Illness Respite Care
Primary
3162012
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3162012
AZ DEPT OF HEALTH SERVICES
AZ
Enumeration date
11/22/2011
Last updated
08/17/2020
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