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General NPI Number Information
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NPI Number | 1659998201
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Entity Type | Individual
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Provider Name | LAURA MACK MA, LADC, LCMHC
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Gender | Female
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Dates
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Enumeration Date | 06/30/2020
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Last Update Date | 12/10/2024
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Provider Practice Location Address
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Address Line | 85 MECHANIC ST
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City | LEBANON
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State | NH
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Zip | 03766-1537
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Country | US
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Telephone | 603-653-1860
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 671
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City | BRADFORD
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State | VT
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Zip | 05033-0671
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Country | US
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Telephone | 802-595-3537
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 151.0129414
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License Number State | VT
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 068.0132901
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License Number State | VT
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 2666
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License Number State | NH
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