Healthcare Provider Details

I. General information

NPI: 1932015062
Provider Name (Legal Business Name): DEMETRA LASJONE MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19963 LORENA CIR
CASTRO VALLEY CA
94546-4200
US

IV. Provider business mailing address

19963 LORENA CIR
CASTRO VALLEY CA
94546-4200
US

V. Phone/Fax

Practice location:
  • Phone: 510-978-5226
  • Fax:
Mailing address:
  • Phone: 510-978-5226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberA7482DACA6
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: