Basic Information
| Provider Information | |||||||||
| NPI: | 1952579716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | AAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 WASHINGTON AVENUE | ||||||||
| Address2: | |||||||||
| City: | BATAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852194989 | ||||||||
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| Practice Location | |||||||||
| Address1: | 422 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145691023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857868133 | ||||||||
| FaxNumber: | 5857869928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2008 | ||||||||
| LastUpdateDate: | 02/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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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) |
ID Information
| ID | Type | State | Issuer | Description | 00740423 | 05 | NY | MEDICAID |