Provider Demographics
NPI:1720632698
Name:MACON, ROBIN DENISE
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:DENISE
Last Name:MACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 ENTERPRISE DR STE B
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-5697
Mailing Address - Country:US
Mailing Address - Phone:229-293-0132
Mailing Address - Fax:
Practice Address - Street 1:1905 S HUTCHINSON AVE
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-5246
Practice Address - Country:US
Practice Address - Phone:229-896-4559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2025-05-26
Deactivation Date:2023-07-31
Deactivation Code:
Reactivation Date:2023-10-06
Provider Licenses
StateLicense IDTaxonomies
GACSW0080931041C0700X
GAMSW008436104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical