Provider Demographics
NPI:1639413966
Name:WILLIS, CRYSTAL LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LYNN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 LEM EDWARDS RD
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30683-2021
Mailing Address - Country:US
Mailing Address - Phone:706-255-1093
Mailing Address - Fax:
Practice Address - Street 1:775 SUNSET DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2211
Practice Address - Country:US
Practice Address - Phone:706-425-1543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002045225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant