Provider Demographics
NPI:1619326584
Name:WYLLOWSWAY, LLC
Entity Type:Organization
Organization Name:WYLLOWSWAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:GERA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:IRVINE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC,CEAP,
Authorized Official - Phone:478-361-2875
Mailing Address - Street 1:105 WILLIAM WAY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-6160
Mailing Address - Country:US
Mailing Address - Phone:478-327-7683
Mailing Address - Fax:478-781-1395
Practice Address - Street 1:105 WILLIAM WAY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31216-6160
Practice Address - Country:US
Practice Address - Phone:478-327-7683
Practice Address - Fax:478-781-1395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-10
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC3186251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health