Provider Demographics
NPI:1588273528
Name:WILLOW OAK FOUNDATION, INC.
Entity type:Organization
Organization Name:WILLOW OAK FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/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:770-683-6946
Mailing Address - Street 1:37 CALUMET PARKWAY
Mailing Address - Street 2:BUILDING J, SUITE 102
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-7856
Mailing Address - Country:US
Mailing Address - Phone:770-683-6946
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:770-683-6949
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLOW OAK COMMUNITY BEHAVIORAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-27
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)