Provider Demographics
NPI:1962555995
Name:MACK, DELORES ELIZA (PHD)
Entity type:Individual
Prefix:DR
First Name:DELORES
Middle Name:ELIZA
Last Name:MACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2176 N ALBRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1217
Mailing Address - Country:US
Mailing Address - Phone:909-946-7177
Mailing Address - Fax:909-946-7133
Practice Address - Street 1:414 YALE AVE
Practice Address - Street 2:SUITE F
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4357
Practice Address - Country:US
Practice Address - Phone:909-319-9956
Practice Address - Fax:909-946-7133
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13593103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4067536Medicaid