Provider Demographics
NPI:1356141626
Name:WILLIS, GINA
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 BEAVERDAM RD APT F
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30683-3931
Mailing Address - Country:US
Mailing Address - Phone:706-207-4796
Mailing Address - Fax:
Practice Address - Street 1:159 ONETA ST STE 4
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-1804
Practice Address - Country:US
Practice Address - Phone:706-207-4796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT013287225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist