Provider Demographics
NPI:1851349104
Name:WILBANKS, MARIJANE C (MSW, MA, BA)
Entity Type:Individual
Prefix:
First Name:MARIJANE
Middle Name:C
Last Name:WILBANKS
Suffix:
Gender:F
Credentials:MSW, MA, BA
Other - Prefix:
Other - First Name:MARIJANE
Other - Middle Name:
Other - Last Name:CIRAVOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2244
Mailing Address - Country:US
Mailing Address - Phone:706-542-0333
Mailing Address - Fax:706-542-9693
Practice Address - Street 1:250 NORTH AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-2244
Practice Address - Country:US
Practice Address - Phone:706-542-0333
Practice Address - Fax:706-542-9693
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0021451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBDKXMedicare ID - Type Unspecified