Healthcare Provider Details

I. General information

NPI: 1588273528
Provider Name (Legal Business Name): WILLOW OAK FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 JEFFERSON PKWY # 55B
NEWNAN GA
30263-5813
US

IV. Provider business mailing address

55 JEFFERSON PKWY # 55B
NEWNAN GA
30263-5813
US

V. Phone/Fax

Practice location:
  • Phone: 770-683-6946
  • Fax: 770-683-6949
Mailing address:
  • Phone: 770-683-6946
  • Fax: 770-683-6949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DIANE BOULAI
Title or Position: OWNER/CEO
Credential:
Phone: 770-683-6946