MEDICARE: WOMBLE COUNSELING SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1447918255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOMBLE COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	120 DONELSON PIKE STE 102
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37214-2911
Country	:	US
Telephone Number	:	615-962-3181
Fax Number	:	615-962-9874

Provider Business Practice Location Address
First Line	:	120 DONELSON PIKE STE 102
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37214-2911
Country	:	US
Telephone Number	:	615-962-3181
Fax Number	:	615-962-9874

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DEXTER PIERRE WOMBLE
Credential	:	LPC-MHSP
Telephone Number	:	615-962-3181

Provider Enumeration Date	:	11/30/2021
Last Update Date	:	11/30/2021

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