Provider Demographics
NPI:1124658356
Name:MACK, E'LON
Entity type:Individual
Prefix:
First Name:E'LON
Middle Name:
Last Name:MACK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 NE 89TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6057
Mailing Address - Country:US
Mailing Address - Phone:360-931-1137
Mailing Address - Fax:
Practice Address - Street 1:1498 SE TECH CENTER PL STE 180
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5518
Practice Address - Country:US
Practice Address - Phone:360-931-1137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 106S00000X
WAMC61661558101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician