Provider Demographics
NPI:1154077279
Name:WOMACK, TEASIA M
Entity Type:Individual
Prefix:
First Name:TEASIA
Middle Name:M
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 1:6025 SPORTS VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-3505
Mailing Address - Country:US
Mailing Address - Phone:214-687-9374
Mailing Address - Fax:214-687-9385
Practice Address - Street 1:6025 SPORTS VILLAGE RD
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-3505
Practice Address - Country:US
Practice Address - Phone:214-687-9374
Practice Address - Fax:214-687-9385
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-21-195411106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician