Provider Demographics
NPI:1275853442
Name:WIMBERLY, GEORGIA ANNE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GEORGIA
Middle Name:ANNE
Last Name:WIMBERLY
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 1:1200 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-5220
Mailing Address - Country:US
Mailing Address - Phone:607-757-2171
Mailing Address - Fax:607-757-2535
Practice Address - Street 1:1200 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-5220
Practice Address - Country:US
Practice Address - Phone:607-757-2171
Practice Address - Fax:607-757-2535
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061784-1104100000X
NY0819161041C0700X
NY1621350711041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool