Provider Demographics
NPI:1295194223
Name:CARMACK, GERALD
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:CARMACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 GLISSON RD
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:GA
Mailing Address - Zip Code:30426-4402
Mailing Address - Country:US
Mailing Address - Phone:808-895-9857
Mailing Address - Fax:
Practice Address - Street 1:210 WARD AVE STE 219B
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4003
Practice Address - Country:US
Practice Address - Phone:808-585-1424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
HI103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst