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General NPI Number Information
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NPI Number | 1588273528
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Entity Type | Organization
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Legal Business Name | WILLOW OAK FOUNDATION, INC.
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Dates
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Enumeration Date | 07/27/2020
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Last Update Date | 02/12/2024
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Provider Practice Location Address
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Address Line | 6944 HIGHWAY 85 STE F
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City | RIVERDALE
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State | GA
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Zip | 30274-2960
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Country | US
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Telephone | 770-683-6946
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Fax | 770-683-6949
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Provider Business Mailing Address
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Address Line | 37 CALUMET PARKWAY BUILDING J, SUITE 102
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City | NEWNAN
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State | GA
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Zip | 30263-7856
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Country | US
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Telephone | 770-683-6946
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Fax | 770-683-6949
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Authorized Official
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Title or Position | OWNER/CEO
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Name | DIANE BOULAI
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Credential |
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Telephone | 770-683-6946
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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