Provider Demographics
NPI:1811566144
Name:BOMAR, GRACE (MMFT, TLMFT)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:BOMAR
Suffix:
Gender:F
Credentials:MMFT, TLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 21ST AVE S STE 439
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37212-4350
Mailing Address - Country:US
Mailing Address - Phone:615-212-9612
Mailing Address - Fax:
Practice Address - Street 1:2021 21ST AVE S STE 439
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-4350
Practice Address - Country:US
Practice Address - Phone:615-212-9612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1794106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist