Provider Demographics
NPI:1861946774
Name:WILLIS, ASHLEY H (DPT)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:H
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:C
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:617 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-2044
Mailing Address - Country:US
Mailing Address - Phone:229-377-8646
Mailing Address - Fax:229-336-1151
Practice Address - Street 1:130 E BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1809
Practice Address - Country:US
Practice Address - Phone:229-336-1115
Practice Address - Fax:229-336-1151
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012449225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist