Provider Demographics
NPI:1528418654
Name:WILLIS, PAMELA (CCC-SP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3389
Mailing Address - Country:US
Mailing Address - Phone:678-377-2833
Mailing Address - Fax:
Practice Address - Street 1:545 OLD NORCROSS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3389
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009277235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist