Provider Demographics
NPI:1083204101
Name:MCLANE, WILLIETHIA
Entity Type:Individual
Prefix:
First Name:WILLIETHIA
Middle Name:
Last Name:MCLANE
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 1:256 STONE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-4591
Mailing Address - Country:US
Mailing Address - Phone:470-443-8603
Mailing Address - Fax:
Practice Address - Street 1:1030 FAYETTEVILLE RD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-2921
Practice Address - Country:US
Practice Address - Phone:404-564-0454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker