Provider Demographics
NPI:1922602218
Name:WOMBLE, MICHAEL DEMETRICE (LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DEMETRICE
Last Name:WOMBLE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31059-0129
Mailing Address - Country:US
Mailing Address - Phone:478-696-9596
Mailing Address - Fax:
Practice Address - Street 1:1929 KAREN CIR APT A
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2232
Practice Address - Country:US
Practice Address - Phone:478-696-9596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008214101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional