Provider Demographics
NPI:1043527948
Name:WOMACK, HEATHER L (MFT)
Entity type:Individual
Prefix:MISS
First Name:HEATHER
Middle Name:L
Last Name:WOMACK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-4838
Mailing Address - Country:US
Mailing Address - Phone:310-562-2332
Mailing Address - Fax:650-591-9568
Practice Address - Street 1:1313 LAUREL ST
Practice Address - Street 2:SUITE 212
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-5044
Practice Address - Country:US
Practice Address - Phone:310-562-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC44436106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist