1780228650 NPI number — DANIELLE ANDREE MACK LMSW-CC

Table of content: DANIELLE ANDREE MACK LMSW-CC (NPI 1780228650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780228650 NPI number — DANIELLE ANDREE MACK LMSW-CC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACK
Provider First Name:
DANIELLE
Provider Middle Name:
ANDREE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW-CC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780228650
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7044
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE PORPOISE
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04014-7044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-742-3771
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 GANNETT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04106-5900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-854-1030
Provider Business Practice Location Address Fax Number:
207-899-4623
Provider Enumeration Date:
11/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  MC18207 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: UNKNOWN . This is a "MAINECARE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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