Healthcare Provider Details

I. General information

NPI: 1235607086
Provider Name (Legal Business Name): ALLISON MACK BA, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2018
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 MARTIN RD STE 200
FAIRFIELD CA
94534-8610
US

IV. Provider business mailing address

2420 MARTIN RD STE 200
FAIRFIELD CA
94534-8610
US

V. Phone/Fax

Practice location:
  • Phone: 707-428-4198
  • Fax: 707-399-4521
Mailing address:
  • Phone: 707-989-0028
  • Fax: 707-399-4521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT140824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: