Provider Demographics
NPI:1598098949
Name:WILLIS, LYNYETTA G (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYNYETTA
Middle Name:G
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 N DECATUR RD
Mailing Address - Street 2:SUITE 259
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5305
Mailing Address - Country:US
Mailing Address - Phone:678-549-2209
Mailing Address - Fax:
Practice Address - Street 1:308 CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2506
Practice Address - Country:US
Practice Address - Phone:678-549-2209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003209103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling