Healthcare Provider Details

I. General information

NPI: 1639415078
Provider Name (Legal Business Name): MARY LYNNE MACK PHD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 E WASHINGTON ST STE 300
PHOENIX AZ
85034-1908
US

IV. Provider business mailing address

4600 E WASHINGTON ST STE 300
PHOENIX AZ
85034-1908
US

V. Phone/Fax

Practice location:
  • Phone: 480-737-6076
  • Fax:
Mailing address:
  • Phone: 480-737-6076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2598-057
License Number StateWI

VIII. Authorized Official

Name: DR. MARY LYNNE MACK
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 262-391-2551