Provider Demographics
NPI:1518217405
Name:WILLEY, JANINE CELIA (LMT, CNMT)
Entity Type:Individual
Prefix:MRS
First Name:JANINE
Middle Name:CELIA
Last Name:WILLEY
Suffix:
Gender:F
Credentials:LMT, CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 LOST LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-4864
Mailing Address - Country:US
Mailing Address - Phone:770-630-6942
Mailing Address - Fax:
Practice Address - Street 1:2080 FAIRBURN RD
Practice Address - Street 2:SUITE G
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1064
Practice Address - Country:US
Practice Address - Phone:678-213-4266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT006850171W00000X, 172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
No171W00000XOther Service ProvidersContractor