Provider Demographics
NPI:1831441146
Name:WILLIS, TANYA S
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:S
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11415 LAKE HARDEMAN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:TN
Mailing Address - Zip Code:38052-4237
Mailing Address - Country:US
Mailing Address - Phone:731-609-0238
Mailing Address - Fax:
Practice Address - Street 1:10815 OLD HIGHWAY 64
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-3599
Practice Address - Country:US
Practice Address - Phone:731-658-2510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001707235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist