Provider Demographics
NPI:1003668385
Name:WIMBUSH, SANDRA J (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:WIMBUSH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 822
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-0022
Mailing Address - Country:US
Mailing Address - Phone:404-444-0615
Mailing Address - Fax:
Practice Address - Street 1:212 HAMMERHAWK RD
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-1515
Practice Address - Country:US
Practice Address - Phone:404-444-0615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0056991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical