Provider Demographics
NPI:1104930700
Name:MACK, MARY LOUISE (LCMHCS, NCC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUISE
Last Name:MACK
Suffix:
Gender:F
Credentials:LCMHCS, NCC
Other - Prefix:MS
Other - First Name:M.
Other - Middle Name:
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCMHCS, NCC
Mailing Address - Street 1:1650 GREENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6456
Mailing Address - Country:US
Mailing Address - Phone:910-798-3500
Mailing Address - Fax:910-798-7834
Practice Address - Street 1:1650 GREENFIELD ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6456
Practice Address - Country:US
Practice Address - Phone:910-798-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3559101YP2500X
NCS3559101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005166Medicaid
NC6102583Medicaid