Provider Demographics
NPI:1174002901
Name:WOMBLE, TARA B (LMSW, LCDC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:B
Last Name:WOMBLE
Suffix:
Gender:F
Credentials:LMSW, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 FM 2181 STE 230-517
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76210-4219
Mailing Address - Country:US
Mailing Address - Phone:800-972-0654
Mailing Address - Fax:214-279-5032
Practice Address - Street 1:7535 OAKMONT BLVD STE 101
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4237
Practice Address - Country:US
Practice Address - Phone:800-972-0643
Practice Address - Fax:214-279-5032
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58109104100000X
TX12655101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker