Provider Demographics
NPI:1992110597
Name:FAULK, OCTAVIA (LMSW, EDS)
Entity type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:
Last Name:FAULK
Suffix:
Gender:F
Credentials:LMSW, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-5214
Mailing Address - Country:US
Mailing Address - Phone:229-300-7480
Mailing Address - Fax:
Practice Address - Street 1:1592 NORMAN DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-3581
Practice Address - Country:US
Practice Address - Phone:229-300-7480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2023-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW010634104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty