Provider Demographics
NPI:1871545103
Name:MACK, STEPHEN CHRISTPHER (LSAA)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:CHRISTPHER
Last Name:MACK
Suffix:
Gender:M
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7320 NDCBU
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571
Mailing Address - Country:US
Mailing Address - Phone:505-751-4536
Mailing Address - Fax:
Practice Address - Street 1:413 SIPAPU RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:505-758-5857
Practice Address - Fax:505-758-2832
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM005761101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)