Basic Information
| Provider Information | |||||||||
| NPI: | 1295194223 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARMACK | ||||||||
| FirstName: | GERALD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 816 GLISSON RD | ||||||||
| Address2: | |||||||||
| City: | GIRARD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304264402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8088959857 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 WARD AVE STE 219B | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968144003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085851424 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2016 | ||||||||
| LastUpdateDate: | 02/18/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | HI | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.