1790991990 NPI number — DR. SHIRLEY ANN MACK PH.D., LPC

Table of content: DR. SHIRLEY ANN MACK PH.D., LPC (NPI 1790991990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790991990 NPI number — DR. SHIRLEY ANN MACK PH.D., LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACK
Provider First Name:
SHIRLEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., LPC
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:
1790991990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20466 FLEETWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARPER WOODS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48225-1624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-522-1569
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15501 METROPOLITAN PKWY
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48036-1684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-263-3880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2007

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: 101YM0800X , with the licence number:  6401005017 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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