Provider Demographics
NPI:1336362425
Name:WILLIS, WYCENE (SST I)
Entity Type:Individual
Prefix:
First Name:WYCENE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:SST I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 WILLIS RD
Mailing Address - Street 2:
Mailing Address - City:TALBOTTON
Mailing Address - State:GA
Mailing Address - Zip Code:31827-9310
Mailing Address - Country:US
Mailing Address - Phone:706-269-3942
Mailing Address - Fax:
Practice Address - Street 1:2100 COMER AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8725
Practice Address - Country:US
Practice Address - Phone:706-665-8183
Practice Address - Fax:706-665-8189
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor