Basic Information
| Provider Information | |||||||||
| NPI: | 1790883973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOMACK | ||||||||
| FirstName: | L | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOMACK | ||||||||
| OtherFirstName: | LESLIE | ||||||||
| OtherMiddleName: | MARK | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD, NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043647000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20 GLENLAKE PARKWAY | ||||||||
| Address2: | DEPARTMENT OF BEHAVIORAL HEALTH | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706777370 | ||||||||
| FaxNumber: | 7706777389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW002394 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.