Provider Demographics
NPI:1316671175
Name:MACK, WINDA LANAE (CTC)
Entity type:Individual
Prefix:DR
First Name:WINDA
Middle Name:LANAE
Last Name:MACK
Suffix:
Gender:F
Credentials:CTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7402 CHADWELL CIR UNIT 102
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-3996
Mailing Address - Country:US
Mailing Address - Phone:443-963-9193
Mailing Address - Fax:
Practice Address - Street 1:7402 CHADWELL CIR UNIT 102
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-3996
Practice Address - Country:US
Practice Address - Phone:443-963-9193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral