Basic Information
| Provider Information | |||||||||
| NPI: | 1770056491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MA, OPT, SUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7190 CALVINE RD APT 22 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958235720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164598001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4343 WILLIAMSBOURGH DR | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958232006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163953552 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2019 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.