Provider Demographics
NPI:1194324616
Name:MACK, ASHLEY MICHELLE (LMT)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MICHELLE
Last Name:MACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 LINESHACK LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-2110
Mailing Address - Country:US
Mailing Address - Phone:702-715-7112
Mailing Address - Fax:
Practice Address - Street 1:9525 HILLWOOD DR STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-0596
Practice Address - Country:US
Practice Address - Phone:702-642-5446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNVMT10083OtherSTATE LICENSE
GAMT014566OtherSTATE LICENSE