D'Undra Willis, LICSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

23648 Issued in MN

Practice address

1250 Moore Lake Dr E Ste 205D
Fridley, MN 55432-5176

Phone

(612) 412-4819

Fax

(651) 304-6027

NPI assigned

May 22, 2017

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Journeys: a Pathway /to Healing, LLC

  • Clinical Social Worker
  • Fridley, MN
  • NPI 1386202091
  NPD Authorized official
• Your Story Matters Counseling

  • Community/Behavioral Health Agency
  • Minneapolis, MN
  • NPI 1396424446
  NPD
• Hope & Healing Counseling Services, LLC

  • Community/Behavioral Health Agency
  • Minneapolis, MN
  • NPI 1891091666
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1495411200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1732233600000",
    "number": "1043747926",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1250 MOORE LAKE DR E STE 205D",
            "city": "FRIDLEY",
            "state": "MN",
            "postal_code": "554325176",
            "telephone_number": "612-412-4819",
            "fax_number": "651-304-6027"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1250 MOORE LAKE DR E STE 205D",
            "city": "FRIDLEY",
            "state": "MN",
            "postal_code": "554325176",
            "telephone_number": "612-412-4819",
            "fax_number": "651-304-6027"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILLIS",
        "first_name": "D'UNDRA",
        "credential": "LICSW",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2017-05-22",
        "last_updated": "2024-11-22",
        "certification_date": "2024-11-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MN",
            "license": "23648",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MN BOARD OF SW",
            "identifier": "23648",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DRIVERS LISCENSE",
            "identifier": "Q577186700819",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Ebony Shawntil Williams
• Jeff Williams
• Jennifer Leanne Williams, P.T.
• Nanette Williams, LMT, L.E.
• Sinah L Williams
• Willows Bend Senior Living LLC
• Marion Wilson
• Phuong T Wippler, PHARMD
• Kristina L Withers, DPT
• William Allen Wittchow, PA-C

• Clinical Social Worker in Fridley, MN
• Providers in Fridley, MN by specialty
• Clinical Social Worker in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 22, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.