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General NPI Number Information
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NPI Number | 1518217405
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Entity Type | Individual
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Provider Name | JANINE CELIA WILLEY L.M.T., C.N.M.T
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Gender | Female
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Dates
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Enumeration Date | 09/18/2012
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Last Update Date | 09/18/2012
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Provider Practice Location Address
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Address Line | 2080 FAIRBURN RD SUITE G
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City | DOUGLASVILLE
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State | GA
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Zip | 30135-1064
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Country | US
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Telephone | 678-213-4266
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Fax |
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Provider Business Mailing Address
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Address Line | 204 LOST LAKE WAY
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City | VILLA RICA
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State | GA
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Zip | 30180-4864
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Country | US
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Telephone | 770-630-6942
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | MT006850
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 172M00000X
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Taxonomy Name | Mechanotherapist
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License Number | MT006850
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License Number State | GA
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