MEDICARE: AMY J WILLIS LCSW

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	1041C0700X	Clinical Social Worker	LSW0000004269	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235229980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY J WILLIS LCSW

Provider Business Mailing Address
First Line	:	2603 OSBORNE RD STE E
Second Line	:
City	:	SAINT MARYS
State	:	GA
Zip	:	31558-8907
Country	:	US
Telephone Number	:	912-510-3420
Fax Number	:	912-510-3425

Provider Business Practice Location Address
First Line	:	2603 OSBORNE RD STE E
Second Line	:
City	:	SAINT MARYS
State	:	GA
Zip	:	31558-8907
Country	:	US
Telephone Number	:	912-510-3420
Fax Number	:	912-510-3425

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	06/07/2022

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