Provider Demographics
NPI:1558109173
Name:MACK, RENEE TIVONI (LCSW, PHD)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:TIVONI
Last Name:MACK
Suffix:
Gender:F
Credentials:LCSW, PHD
Other - Prefix:DR
Other - First Name:RENEE
Other - Middle Name:MACK
Other - Last Name:MAUGEAIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, PHD
Mailing Address - Street 1:13719 VENTURA BLVD # I
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-3032
Mailing Address - Country:US
Mailing Address - Phone:805-953-4221
Mailing Address - Fax:
Practice Address - Street 1:13719 VENTURA BLVD # I
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-3032
Practice Address - Country:US
Practice Address - Phone:805-953-4221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA893591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical