Healthcare Provider Details

I. General information

NPI: 1477743193
Provider Name (Legal Business Name): CARY NELSON MACK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 04/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10517 KENTSHIRE CT
BATON ROUGE LA
70810-2853
US

IV. Provider business mailing address

9229 BLUEBONNET BLVD STE B
BATON ROUGE LA
70810-2808
US

V. Phone/Fax

Practice location:
  • Phone: 225-769-8335
  • Fax: 225-769-8396
Mailing address:
  • Phone: 225-766-7470
  • Fax: 225-766-7473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1035
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: