Provider Demographics
NPI:1316487259
Name:GREGORY I. MACK, PH.D.:CLINICAL, POLICE & FORENSIC PSYCH SVS PLLC
Entity type:Organization
Organization Name:GREGORY I. MACK, PH.D.:CLINICAL, POLICE & FORENSIC PSYCH SVS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:IRVING
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:845-282-3367
Mailing Address - Street 1:PO BOX 533
Mailing Address - Street 2:
Mailing Address - City:SHRUB OAK
Mailing Address - State:NY
Mailing Address - Zip Code:10588-0533
Mailing Address - Country:US
Mailing Address - Phone:845-282-3367
Mailing Address - Fax:914-743-1613
Practice Address - Street 1:345 KEAR ST
Practice Address - Street 2:SUITE 202
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598-4425
Practice Address - Country:US
Practice Address - Phone:845-282-3367
Practice Address - Fax:914-743-1613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-25
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016597103TA0400X, 103TB0200X, 103TC0700X, 103TF0200X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03577942Medicaid