Provider Demographics
NPI:1740936335
Name:WILLOW OAK COMMUNITY BEHAVIORAL HEALTH CENTER, INC.
Entity type:Organization
Organization Name:WILLOW OAK COMMUNITY BEHAVIORAL HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOULAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-477-3476
Mailing Address - Street 1:361 CLIFFHAVEN CIR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-6358
Mailing Address - Country:US
Mailing Address - Phone:678-477-3476
Mailing Address - Fax:770-683-6949
Practice Address - Street 1:6944 HIGHWAY 85 STE F
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2960
Practice Address - Country:US
Practice Address - Phone:770-683-6946
Practice Address - Fax:779-683-6949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-23
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)