Provider Demographics
NPI:1831475318
Name:WILLIS, PATEN LANE (OTR/L)
Entity Type:Individual
Prefix:
First Name:PATEN
Middle Name:LANE
Last Name:WILLIS
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 PAPER TRAIL WAY
Mailing Address - Street 2:STE 302
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-5203
Mailing Address - Country:US
Mailing Address - Phone:770-345-2804
Mailing Address - Fax:678-827-0927
Practice Address - Street 1:310 PAPER TRAIL WAY
Practice Address - Street 2:STE 302
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-5203
Practice Address - Country:US
Practice Address - Phone:770-345-2804
Practice Address - Fax:678-827-0927
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005366225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics