Provider Demographics
NPI:1720820921
Name:MACK, EBONY
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 S WALNUT BEND RD
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7284
Mailing Address - Country:US
Mailing Address - Phone:901-206-5604
Mailing Address - Fax:
Practice Address - Street 1:293 S WALNUT BEND RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7284
Practice Address - Country:US
Practice Address - Phone:901-206-5604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional