Provider Demographics
NPI:1013739911
Name:WILLIS, TAKIYA IREANNA
Entity type:Individual
Prefix:
First Name:TAKIYA
Middle Name:IREANNA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3623 CALVIN DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-7915
Mailing Address - Country:US
Mailing Address - Phone:706-940-5100
Mailing Address - Fax:
Practice Address - Street 1:3623 CALVIN DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-7915
Practice Address - Country:US
Practice Address - Phone:706-940-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-24-389555106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician