Healthcare Provider Details

I. General information

NPI: 1295674935
Provider Name (Legal Business Name): JULIAN MACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4352 W SYLVANIA AVE
TOLEDO OH
43623-3463
US

IV. Provider business mailing address

137 MORRISON ST
FREMONT OH
43420-4416
US

V. Phone/Fax

Practice location:
  • Phone: 544-561-5433
  • Fax:
Mailing address:
  • Phone: 844-561-5433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA193074
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.005327
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: