Provider Demographics
NPI:1720643448
Name:PROTHRO, WILL MCKINNLEY
Entity Type:Individual
Prefix:
First Name:WILL
Middle Name:MCKINNLEY
Last Name:PROTHRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-5244
Mailing Address - Country:US
Mailing Address - Phone:706-324-4061
Mailing Address - Fax:706-317-9895
Practice Address - Street 1:1215 2ND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-5244
Practice Address - Country:US
Practice Address - Phone:706-324-4061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
GA58-2108870103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58-2108870Medicaid