Provider Demographics
NPI:1851118566
Name:MACK, ANDREA (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 AUGUSTA DR APT A
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207-1265
Mailing Address - Country:US
Mailing Address - Phone:480-272-1111
Mailing Address - Fax:
Practice Address - Street 1:3001 AUGUSTA DR APT A
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76207-1265
Practice Address - Country:US
Practice Address - Phone:480-272-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7482103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst