Provider Demographics
NPI:1982471801
Name:WOMBLE, DALLACE (CDCA)
Entity Type:Individual
Prefix:
First Name:DALLACE
Middle Name:
Last Name:WOMBLE
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-3840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4977 NORTHCUTT PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-3839
Practice Address - Country:US
Practice Address - Phone:800-829-5461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA185956101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)