Provider Demographics
NPI:1275262552
Name:WOMACK, THEASIA (RBT)
Entity Type:Individual
Prefix:
First Name:THEASIA
Middle Name:
Last Name:WOMACK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:3338 TRICKUM RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4242
Practice Address - Country:US
Practice Address - Phone:470-472-0039
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-207225106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician