Provider Demographics
NPI:1972144392
Name:MACK, KEVIN (LPC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MACK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7322 SOUTHWEST FWY STE 1055
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-2089
Mailing Address - Country:US
Mailing Address - Phone:462-798-1753
Mailing Address - Fax:
Practice Address - Street 1:7322 SOUTHWEST FWY STE 1055
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-2089
Practice Address - Country:US
Practice Address - Phone:462-798-1753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82836101YA0400X, 101Y00000X, 101YM0800X, 101YP1600X, 101YS0200X, 106H00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX27286854OtherDRIVERS LICENSE