Provider Demographics
NPI:1346899499
Name:MACK, ANGELL Y (CADC)
Entity type:Individual
Prefix:
First Name:ANGELL
Middle Name:Y
Last Name:MACK
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-4930
Mailing Address - Country:US
Mailing Address - Phone:217-544-4631
Mailing Address - Fax:
Practice Address - Street 1:620 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4930
Practice Address - Country:US
Practice Address - Phone:217-544-4631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)