Healthcare Provider Details

I. General information

NPI: 1104930700
Provider Name (Legal Business Name): MARY LOUISE MACK LCMHCS, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: M. MACK LCMHCS, NCC

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GREENFIELD ST
WILMINGTON NC
28401-6456
US

IV. Provider business mailing address

1650 GREENFIELD ST
WILMINGTON NC
28401-6456
US

V. Phone/Fax

Practice location:
  • Phone: 910-798-3500
  • Fax:
Mailing address:
  • Phone: 910-798-3500
  • Fax: 910-798-7834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS3559
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3559
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: