Provider Demographics
NPI:1134853187
Name:WOOLSEY, SAMUEL LEWIS
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LEWIS
Last Name:WOOLSEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 PERKINS MILL RD
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-6465
Mailing Address - Country:US
Mailing Address - Phone:912-567-5730
Mailing Address - Fax:912-221-3711
Practice Address - Street 1:1213 PERKINS MILL RD
Practice Address - Street 2:
Practice Address - City:CLAXTON
Practice Address - State:GA
Practice Address - Zip Code:30417-6465
Practice Address - Country:US
Practice Address - Phone:912-567-5730
Practice Address - Fax:912-221-3711
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-154412106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician