Provider Demographics
NPI:1164030904
Name:MACK, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:MACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 CARIBBEAN DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-3932
Mailing Address - Country:US
Mailing Address - Phone:833-869-2423
Mailing Address - Fax:
Practice Address - Street 1:1820 ARMSTRONG BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2589
Practice Address - Country:US
Practice Address - Phone:407-966-3070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2023-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-131232106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-20-131232OtherRBT CERTIFICATION
FL107662000Medicaid