Provider Demographics
NPI:1093218349
Name:WILLIS, ROBERT LAWRENCE (LAPC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LAWRENCE
Last Name:WILLIS
Suffix:
Gender:M
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-5515
Mailing Address - Country:US
Mailing Address - Phone:229-219-1831
Mailing Address - Fax:229-219-1832
Practice Address - Street 1:111 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-5515
Practice Address - Country:US
Practice Address - Phone:229-219-1831
Practice Address - Fax:229-219-1832
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006297101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty