Basic Information
Provider Information
NPI: 1003005216
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WOMACK
FirstName: KIMBERLEY
MiddleName: J
NamePrefix: MS.
NameSuffix:  
Credential: LCSW, PIP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2109 SCENIC DR
Address2:  
City: GADSDEN
State: AL
PostalCode: 359043254
CountryCode: US
TelephoneNumber: 2565491168
FaxNumber:  
Practice Location
Address1: 901 GOODYEAR AVE
Address2:  
City: GADSDEN
State: AL
PostalCode: 359031106
CountryCode: US
TelephoneNumber: 2564927800
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/24/2007
LastUpdateDate: 10/24/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700XPIP268-1020CALY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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