=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699006270
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA MACK LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2010
-----------------------------------------------------
Last Update Date | 05/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 MANCHESTER ROAD
-----------------------------------------------------
City | WHEATON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60187-4593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-880-8445
-----------------------------------------------------
Fax | 630-953-2559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 544 S HIGHLAND AVE
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148-3053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-880-8445
-----------------------------------------------------
Fax | 630-953-2559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 166.000595
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------