Provider Demographics
NPI:1588761530
Name:MACK, DESRA (LPC)
Entity type:Individual
Prefix:MRS
First Name:DESRA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4300 SAPPHIRE CT STE 110
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-9079
Mailing Address - Country:US
Mailing Address - Phone:252-830-7540
Mailing Address - Fax:252-413-0932
Practice Address - Street 1:1141 N ROAD ST
Practice Address - Street 2:SUITE L
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3354
Practice Address - Country:US
Practice Address - Phone:252-335-0803
Practice Address - Fax:252-331-1796
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5415101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103306Medicaid