Provider Demographics
NPI:1982986865
Name:WILLIS, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 IVY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-2149
Mailing Address - Country:US
Mailing Address - Phone:908-672-4009
Mailing Address - Fax:
Practice Address - Street 1:141 IVY ST
Practice Address - Street 2:
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080-2149
Practice Address - Country:US
Practice Address - Phone:908-672-4009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00527900235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist