Basic Information
| Provider Information | |||||||||
| NPI: | 1699177311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARMACK | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | CARMACK | ||||||||
| OtherFirstName: | STACI | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | B.A. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 900 BEASLEY ST | ||||||||
| Address2: | SUITE120 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405094266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133222400 | ||||||||
| FaxNumber: | 9136215730 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 BEASLEY ST | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405094266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594754409 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | KY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.