=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932472685
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HALLEY M CARMACK LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2012
-----------------------------------------------------
Last Update Date | 04/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 SE 6TH AVE STE 200E
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33483-5306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-501-0188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 TROPICAL DR APT 5
-----------------------------------------------------
City | OCEAN RIDGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33435-7030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-573-0235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C008379
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW16627
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------