Provider Demographics
NPI:1053976381
Name:WOMACK, CAROLYN D (LCSW)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:D
Last Name:WOMACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1216
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-1216
Mailing Address - Country:US
Mailing Address - Phone:662-624-4292
Mailing Address - Fax:662-624-4354
Practice Address - Street 1:800 OHIO AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-7200
Practice Address - Country:US
Practice Address - Phone:662-624-2504
Practice Address - Fax:662-627-3629
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC60511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08101973Medicaid