Provider Demographics
NPI:1073140109
Name:WOOLWINE, BOBBI JEAN
Entity Type:Individual
Prefix:
First Name:BOBBI
Middle Name:JEAN
Last Name:WOOLWINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 VIDAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2346
Mailing Address - Country:US
Mailing Address - Phone:404-964-1696
Mailing Address - Fax:
Practice Address - Street 1:12 EXECUTIVE PARK DR NE FL 2
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2206
Practice Address - Country:US
Practice Address - Phone:404-727-8382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0039611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical