Provider Demographics
NPI:1750931200
Name:WILLIS, ROBERT K (MED)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:K
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2818 APPALOOSA RUN
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-3968
Mailing Address - Country:US
Mailing Address - Phone:404-630-5301
Mailing Address - Fax:
Practice Address - Street 1:2818 APPALOOSA RUN
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-3968
Practice Address - Country:US
Practice Address - Phone:404-630-5301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1366328101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool