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General NPI Number Information
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NPI Number | 1427290261
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Entity Type | Organization
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Legal Business Name | WILLOW CREEK SUBSTANCE ABUSE PROGRAM
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Dates
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Enumeration Date | 03/25/2009
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Last Update Date | 03/25/2009
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Provider Practice Location Address
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Address Line | 10 KIKER ST
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City | ELLIJAY
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State | GA
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Zip | 30540-3700
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Country | US
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Telephone | 706-636-2692
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Fax | 760-636-2694
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Provider Business Mailing Address
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Address Line | 10 KIKER ST
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City | ELLIJAY
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State | GA
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Zip | 30540-3700
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Country | US
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Telephone | 706-636-2692
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Fax | 760-636-2694
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Authorized Official
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Title or Position | DIRECTOR
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Name | LARRY W HOOKS
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Credential | LPC
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Telephone | 706-636-2692
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | LPC003706
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License Number State | GA
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