Provider Demographics
NPI:1861922833
Name:MACK, KERI MARIE (BCBA)
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:MARIE
Last Name:MACK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KERI
Other - Middle Name:MARIE
Other - Last Name:GUTEKUNST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:44670 ANN ARBOR RD W STE 130
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4085
Mailing Address - Country:US
Mailing Address - Phone:313-657-4860
Mailing Address - Fax:
Practice Address - Street 1:44670 ANN ARBOR RD W STE 130
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4085
Practice Address - Country:US
Practice Address - Phone:313-278-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician