Healthcare Provider Details

I. General information

NPI: 1770605370
Provider Name (Legal Business Name): MARILYN YVONNE WHITEHURST LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3575 MACON RD STE 18
COLUMBUS GA
31907
US

IV. Provider business mailing address

3575 MACON RD STE 18
COLUMBUS GA
31907-8236
US

V. Phone/Fax

Practice location:
  • Phone: 706-565-5927
  • Fax: 706-565-8207
Mailing address:
  • Phone: 706-565-5927
  • Fax: 706-565-8207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003348
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: