Provider Demographics
NPI:1528055399
Name:CAMMACK, RAY EDWARD (M ED, LCPC)
Entity type:Individual
Prefix:MR
First Name:RAY
Middle Name:EDWARD
Last Name:CAMMACK
Suffix:
Gender:M
Credentials:M ED, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5420 W FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1071
Mailing Address - Country:US
Mailing Address - Phone:208-420-5380
Mailing Address - Fax:
Practice Address - Street 1:5420 W FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1071
Practice Address - Country:US
Practice Address - Phone:208-420-5380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3129261QM0801X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1861500035Medicaid