Provider Demographics
NPI:1831670967
Name:GEORGE, WILLIE FLORENCE
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:FLORENCE
Last Name:GEORGE
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 1:23021 RADCLIFT ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2418
Mailing Address - Country:US
Mailing Address - Phone:248-967-1178
Mailing Address - Fax:
Practice Address - Street 1:23021 RADCLIFT ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2418
Practice Address - Country:US
Practice Address - Phone:248-967-1178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF630080656253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency