Provider Demographics
NPI:1063714566
Name:MACK, CAROL (PSYD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 N. CLAUDE A. LORD BLVD.
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-2706
Mailing Address - Country:US
Mailing Address - Phone:570-622-1025
Mailing Address - Fax:570-628-4344
Practice Address - Street 1:454 N. CLAUDE A. LORD BLVD.
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2706
Practice Address - Country:US
Practice Address - Phone:570-622-1025
Practice Address - Fax:570-628-4344
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC003007101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional