Provider Demographics
NPI:1295809952
Name:BRACKETT, CAROL LOU (PHD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:LOU
Last Name:BRACKETT
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 1:207 B ROCK PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845
Mailing Address - Country:US
Mailing Address - Phone:979-690-9301
Mailing Address - Fax:979-694-7337
Practice Address - Street 1:207 B ROCK PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845
Practice Address - Country:US
Practice Address - Phone:979-690-9301
Practice Address - Fax:979-694-7337
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3830103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0334S4201Medicaid
00G34YMedicare ID - Type Unspecified