Provider Demographics
NPI:1326515750
Name:CARMACK, TERESA KAY
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:KAY
Last Name:CARMACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 1061
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78957
Mailing Address - Country:US
Mailing Address - Phone:512-237-0087
Mailing Address - Fax:
Practice Address - Street 1:CARE INN OF LA GRANGE
Practice Address - Street 2:457 N. MAIN STREET
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945
Practice Address - Country:US
Practice Address - Phone:979-968-5865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100733225XN1300X, 225XP0019X, 225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation