Provider Demographics
NPI:1407122948
Name:WILLIS, RENEE (LPC, RPT, NCC)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LPC, RPT, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WETLANDS RD
Mailing Address - Street 2:
Mailing Address - City:WHITE
Mailing Address - State:GA
Mailing Address - Zip Code:30184-2885
Mailing Address - Country:US
Mailing Address - Phone:657-229-0679
Mailing Address - Fax:
Practice Address - Street 1:109 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3905
Practice Address - Country:US
Practice Address - Phone:657-229-0679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008460101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional