Healthcare Provider Details

I. General information

NPI: 1841967841
Provider Name (Legal Business Name): DANIEL WILLIAM MACKE LAPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 S BERKELEY LAKE RD
BERKELEY LAKE GA
30071-1660
US

IV. Provider business mailing address

3795 DALWOOD DR
SUWANEE GA
30024-6642
US

V. Phone/Fax

Practice location:
  • Phone: 678-650-3289
  • Fax:
Mailing address:
  • Phone: 678-650-3289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAPC006813
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: