Provider Demographics
NPI:1205486867
Name:CARMACK, ARIEL AMBER-LYNN
Entity type:Individual
Prefix:
First Name:ARIEL
Middle Name:AMBER-LYNN
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 1:4017 GERMAN POINTER WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-3531
Mailing Address - Country:US
Mailing Address - Phone:682-352-7000
Mailing Address - Fax:
Practice Address - Street 1:6040 CAMP BOWIE BLVD STE 29
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5602
Practice Address - Country:US
Practice Address - Phone:682-352-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT116825225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty