Provider Demographics
NPI:1871913087
Name:MACK, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3490 BULLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-4615
Mailing Address - Country:US
Mailing Address - Phone:706-394-4357
Mailing Address - Fax:
Practice Address - Street 1:3711 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 202 OFFICE #3
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-0951
Practice Address - Country:US
Practice Address - Phone:706-394-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-27
Last Update Date:2014-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006746101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional