Healthcare Provider Details

I. General information

NPI: 1669523106
Provider Name (Legal Business Name): GREGORY IRVING MACK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 02/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 KEAR ST SUITE 202
YORKTOWN HEIGHTS NY
10598-4425
US

IV. Provider business mailing address

PO BOX 533
SHRUB OAK NY
10588-0533
US

V. Phone/Fax

Practice location:
  • Phone: 845-282-3367
  • Fax: 914-743-1613
Mailing address:
  • Phone: 845-282-3367
  • Fax: 914-743-1613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number016597
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number016597
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number016597
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number016597
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number016597
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: