Provider Demographics
NPI:1801028758
Name:WOMACK, GRACE BROWN
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:BROWN
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 1:2101 PONDEROSA ST APT 6B
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-7945
Mailing Address - Country:US
Mailing Address - Phone:714-412-8976
Mailing Address - Fax:
Practice Address - Street 1:2521 N GRAND AVE STE B
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8725
Practice Address - Country:US
Practice Address - Phone:714-532-2526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-11
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 322671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical