Provider Demographics
NPI:1982018370
Name:WILLIS, STACY L (BS)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 CADDENWOODS DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-5618
Mailing Address - Country:US
Mailing Address - Phone:706-751-4089
Mailing Address - Fax:
Practice Address - Street 1:1007 CADDENWOODS DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-5618
Practice Address - Country:US
Practice Address - Phone:706-751-4089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALCB201400000776171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator