Provider Demographics
NPI:1073660262
Name:CHICOTA-CARROLL, CAMMY (PHD)
Entity Type:Individual
Prefix:
First Name:CAMMY
Middle Name:
Last Name:CHICOTA-CARROLL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3339 FALLING BRK STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4432
Mailing Address - Country:US
Mailing Address - Phone:719-650-9967
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-7641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003655103G00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX37844OtherLICENSE