Basic Information
| Provider Information | |||||||||
| NPI: | 1891709234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARMACK | ||||||||
| FirstName: | ALFRED | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARMACK | ||||||||
| OtherFirstName: | FRED | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMHC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 313 SEDILLO HILL RD | ||||||||
| Address2: | |||||||||
| City: | TIJERAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870597389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 313 SEDILLO HILL RD | ||||||||
| Address2: | |||||||||
| City: | TIJERAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870597389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0080291 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0080291 | 01 | NM | LMHC | OTHER |