Basic Information
| Provider Information | |||||||||
| NPI: | 1538210463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | VALERIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHELTON | ||||||||
| OtherFirstName: | VALERIE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 42 DELSEA DR S | ||||||||
| Address2: | |||||||||
| City: | GLASSBORO | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080282621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568630006 | ||||||||
| FaxNumber: | 8568817614 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 DELSEA DR S | ||||||||
| Address2: | |||||||||
| City: | GLASSBORO | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080282621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568630006 | ||||||||
| FaxNumber: | 8568817614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 37PC00346500 | NJ | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2785982000 | 01 | NE | AMERIHEALTH | OTHER |