Provider Demographics
NPI:1699177311
Name:CARMACK, STACI
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:CARMACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:LYNN
Other - Last Name:CARMACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA
Mailing Address - Street 1:900 BEASLEY ST
Mailing Address - Street 2:SUITE120
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-4266
Mailing Address - Country:US
Mailing Address - Phone:913-322-2400
Mailing Address - Fax:913-621-5730
Practice Address - Street 1:900 BEASLEY ST
Practice Address - Street 2:SUITE 120
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-4266
Practice Address - Country:US
Practice Address - Phone:859-475-4409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker