Provider Demographics
NPI:1528787447
Name:WOMACK, MATTHEW LUCAS (LMSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LUCAS
Last Name:WOMACK
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:LUCAS
Other - Middle Name:
Other - Last Name:WOMACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:2832 44TH ST APT 32
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-2171
Mailing Address - Country:US
Mailing Address - Phone:423-368-5778
Mailing Address - Fax:
Practice Address - Street 1:307 W 38TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-2913
Practice Address - Country:US
Practice Address - Phone:212-367-1284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117060-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker