Healthcare Provider Details

I. General information

NPI: 1255849758
Provider Name (Legal Business Name): RANDALL CARMACK LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELIZABETH PL FL 3
DAYTON OH
45417-3445
US

IV. Provider business mailing address

3103 DIXIE HWY
HAMILTON OH
45015-1653
US

V. Phone/Fax

Practice location:
  • Phone: 937-815-6233
  • Fax:
Mailing address:
  • Phone: 513-892-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number162422
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2507266
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number162458
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCDCIII.162264
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.000660
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: