Basic Information
| Provider Information | |||||||||
| NPI: | 1902197114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | TAIA | ||||||||
| MiddleName: | LASHAWN | ||||||||
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| Credential: | AMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5674 STONERIDGE DR. | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | PLEASANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9255200005 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1700 BROADWAY STREET | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9255200005 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2011 | ||||||||
| LastUpdateDate: | 03/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 60249 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.