Provider Demographics
NPI:1073110508
Name:WOMACK, TIA DENISE
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:DENISE
Last Name:WOMACK
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 1:12226 GLIMMER WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32219-1864
Mailing Address - Country:US
Mailing Address - Phone:904-482-9316
Mailing Address - Fax:
Practice Address - Street 1:2392 EDGEWOOD AVE N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-1725
Practice Address - Country:US
Practice Address - Phone:904-781-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor