Provider Demographics
NPI:1730242009
Name:BACON-WHITTED, CYNTHIA (LCSW)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:BACON-WHITTED
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162391
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30321-2391
Mailing Address - Country:US
Mailing Address - Phone:404-483-0577
Mailing Address - Fax:
Practice Address - Street 1:6200 RIVEROAK TER
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-4095
Practice Address - Country:US
Practice Address - Phone:404-483-0577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW002077104100000X
GACSW0059451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000849032AMedicaid