Provider Demographics
NPI:1871318386
Name:MACK, SALLIE (PHD)
Entity type:Individual
Prefix:DR
First Name:SALLIE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2747 ARBOR AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30317-2903
Mailing Address - Country:US
Mailing Address - Phone:404-409-1533
Mailing Address - Fax:
Practice Address - Street 1:4268 CANTON RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-8301
Practice Address - Country:US
Practice Address - Phone:404-692-4037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004840103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist