Healthcare Provider Details

I. General information

NPI: 1740703651
Provider Name (Legal Business Name): GREG WOMBLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 N SCHOOL ST STE 308
LODI CA
95240-2161
US

IV. Provider business mailing address

104 N SCHOOL ST STE 308
LODI CA
95240-2161
US

V. Phone/Fax

Practice location:
  • Phone: 209-370-5901
  • Fax:
Mailing address:
  • Phone: 209-370-5901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: