Provider Demographics
NPI:1194381244
Name:WOMACK, MAKENSEY SWANSON
Entity Type:Individual
Prefix:
First Name:MAKENSEY
Middle Name:SWANSON
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 1:363 S PINE COVE LN
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-2405
Mailing Address - Country:US
Mailing Address - Phone:801-510-6210
Mailing Address - Fax:
Practice Address - Street 1:515 700 EAST
Practice Address - Street 2:SUITE 2A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UTAH
Practice Address - Zip Code:84102
Practice Address - Country:UM
Practice Address - Phone:800-434-8929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician