Provider Demographics
NPI:1306200670
Name:WILLARD, CYNTHIA (MT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:WILLARD
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 ATLANTA HWY
Mailing Address - Street 2:1702B
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-8099
Mailing Address - Country:US
Mailing Address - Phone:770-722-2711
Mailing Address - Fax:
Practice Address - Street 1:2450 ATLANTA HWY
Practice Address - Street 2:1702B
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-8099
Practice Address - Country:US
Practice Address - Phone:770-722-2711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT003367225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist