Healthcare Provider Details

I. General information

NPI: 1124116686
Provider Name (Legal Business Name): MICHAEL GUY CAMMACK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2481 LLEWELLYN AVE BHCS, USA MEDDAC
FORT MEADE MD
20755-5800
US

IV. Provider business mailing address

1603 SHERWOOD RD
SILVER SPRING MD
20902-3960
US

V. Phone/Fax

Practice location:
  • Phone: 301-677-8895
  • Fax: 301-677-8957
Mailing address:
  • Phone: 301-592-8447
  • Fax: 301-677-8967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3057
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: