Provider Demographics
NPI:1861929689
Name:MACK, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 N COUNTRY CLUB DR STE 19
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-2560
Mailing Address - Country:US
Mailing Address - Phone:520-582-7418
Mailing Address - Fax:
Practice Address - Street 1:1530 N COUNTRY CLUB DR STE 19
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-2560
Practice Address - Country:US
Practice Address - Phone:520-582-7418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist