Provider Demographics
NPI:1205258449
Name:MACK, AMY JANE-BOLT (LMSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JANE-BOLT
Last Name:MACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 OAKLAND DR
Mailing Address - Street 2:3RD FLOOR CTAC
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1282
Mailing Address - Country:US
Mailing Address - Phone:269-329-8297
Mailing Address - Fax:269-387-7050
Practice Address - Street 1:605 HOWARD ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1919
Practice Address - Country:US
Practice Address - Phone:269-329-8297
Practice Address - Fax:269-387-7050
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6901089181101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health