Healthcare Provider Details

I. General information

NPI: 1528055399
Provider Name (Legal Business Name): RAY EDWARD CAMMACK M. ED., LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 S MARSH WOOD PL
MERIDIAN ID
83642-7457
US

IV. Provider business mailing address

1835 S MARSH WOOD PL
MERIDIAN ID
83642-7457
US

V. Phone/Fax

Practice location:
  • Phone: 208-420-5380
  • Fax:
Mailing address:
  • Phone: 208-420-5380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-3129
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC-3129
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberLCPC-3129
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: