Provider Demographics
NPI:1063721173
Name:WOMACK, JOHANNA MARIE (MA LPC)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:MARIE
Last Name:WOMACK
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:MARIE
Other - Last Name:CORTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:417-761-5000
Mailing Address - Fax:417-761-5065
Practice Address - Street 1:520 RYAN ST STE W
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-1894
Practice Address - Country:US
Practice Address - Phone:660-882-7573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010027678101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494287808Medicaid