Provider Demographics
NPI:1508280942
Name:WASHINGTON, THELMA
Entity Type:Individual
Prefix:MRS
First Name:THELMA
Middle Name:
Last Name:WASHINGTON
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 1:8060 WEBB RD UNIT 741732
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-5426
Mailing Address - Country:US
Mailing Address - Phone:404-409-3888
Mailing Address - Fax:770-991-7727
Practice Address - Street 1:710 KING RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2027
Practice Address - Country:US
Practice Address - Phone:404-409-3888
Practice Address - Fax:770-991-7727
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
GAMSW006347104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003143435AMedicaid