Provider Demographics
NPI:1417797747
Name:MACK, SHEILA M
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHEILA
Other - Middle Name:M
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:827 W PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8459
Mailing Address - Country:US
Mailing Address - Phone:208-719-7158
Mailing Address - Fax:208-500-2508
Practice Address - Street 1:827 W PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8459
Practice Address - Country:US
Practice Address - Phone:208-719-7158
Practice Address - Fax:208-500-2508
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician