Healthcare Provider Details

I. General information

NPI: 1891709234
Provider Name (Legal Business Name): ALFRED B. CARMACK LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: FRED CARMACK LMHC

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 SEDILLO HILL RD
TIJERAS NM
87059-7389
US

IV. Provider business mailing address

313 SEDILLO HILL RD
TIJERAS NM
87059-7389
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 505-265-1711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0080291
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: