Provider Demographics
NPI:1235229980
Name:WILLIS, AMY J (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:CAROL
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2603 OSBORNE RD STE E
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-8907
Mailing Address - Country:US
Mailing Address - Phone:912-510-3420
Mailing Address - Fax:912-510-3425
Practice Address - Street 1:2603 OSBORNE RD STE E
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-8907
Practice Address - Country:US
Practice Address - Phone:912-510-3420
Practice Address - Fax:912-510-3425
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000042691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3698356Medicaid
TN103I807427Medicare PIN
TN3698356Medicare PIN
TN3698356Medicaid