Provider Demographics
NPI:1215105556
Name:MACK, CATHY (LPC)
Entity type:Individual
Prefix:
First Name:CATHY
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S JT STITES BLVD
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-9301
Mailing Address - Country:US
Mailing Address - Phone:918-775-7787
Mailing Address - Fax:918-775-0328
Practice Address - Street 1:205 S JT STITES BLVD
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-9301
Practice Address - Country:US
Practice Address - Phone:918-775-7787
Practice Address - Fax:918-775-3580
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3692101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200360410AMedicaid