Wesley Demarius Willis, PSY.D, LCSW-R, RN

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

076729 Issued in NY

Practice address

1740 Broadway FL 15
New York, NY 10019-4605

Phone

(347) 502-0965

Fax

(917) 725-8319

NPI assigned

May 1, 2007

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Registered Nurse

State licenses

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

{
    "created_epoch": "1177977600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1712102400000",
    "number": "1629299664",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3016 31ST ST",
            "address_2": "1ST FLOOR",
            "city": "ASTORIA",
            "state": "NY",
            "postal_code": "111022269",
            "telephone_number": "347-502-0965",
            "fax_number": "718-559-6473"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1740 BROADWAY FL 15",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100194605",
            "telephone_number": "347-502-0965",
            "fax_number": "917-725-8319"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILLIS",
        "first_name": "WESLEY",
        "middle_name": "DEMARIUS",
        "name_prefix": "Dr.",
        "credential": "PSY.D, LCSW-R, RN",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-05-01",
        "last_updated": "2024-04-03",
        "certification_date": "2024-04-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NY",
            "license": "076729",
            "primary": true
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "NY",
            "license": "650621",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "03152545",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Miles Alves Willis
• Monderrick Willis
• Robert Howard Willis, M.D.
• Rodney Willis Jr.
• Trellane Arthur Willis, MD
• Damon Willlngham Jr., MHC-LP
• Carly Willmes
• Gary S Willner, DC, PT
• Judith Pleasure Willner, M.D.
• Orin L. Willner, L.C.S.W.

• Clinical Social Worker in New York, NY
• Providers in New York, NY by specialty
• Clinical Social Worker in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 3, 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.