Provider Demographics
NPI:1245996826
Name:WOMBLE, BRENT MADDOX (PHD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:MADDOX
Last Name:WOMBLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 RIDGEDALE RD
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-5532
Mailing Address - Country:US
Mailing Address - Phone:940-453-7930
Mailing Address - Fax:
Practice Address - Street 1:109 RIDGEDALE RD
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-5532
Practice Address - Country:US
Practice Address - Phone:940-453-7930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007680103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical