Provider Demographics
NPI:1861220667
Name:WOMACK, MARINA (BCBA)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:WOMACK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 PRINCETON DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-0850
Mailing Address - Country:US
Mailing Address - Phone:716-545-6922
Mailing Address - Fax:
Practice Address - Street 1:540 W THOMAS ST STE C
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2745
Practice Address - Country:US
Practice Address - Phone:716-545-6922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-24-74400103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst