MEDICARE: ROBERT LAWRENCE WILLIS LAPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	APC006297	GA

General Provider Information

NPI Number	:	1093218349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT LAWRENCE WILLIS LAPC

Provider Business Mailing Address
First Line	:	111 N PATTERSON ST
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31601-5515
Country	:	US
Telephone Number	:	229-219-1831
Fax Number	:	229-219-1832

Provider Business Practice Location Address
First Line	:	111 N PATTERSON ST
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31601-5515
Country	:	US
Telephone Number	:	229-219-1831
Fax Number	:	229-219-1832

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2018
Last Update Date	:	03/13/2018

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