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General NPI Number Information
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NPI Number | 1760416903
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Entity Type | Individual
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Provider Name | KEVIN JOSEPH MACK PSY.D.
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Gender | Male
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Dates
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Enumeration Date | 07/11/2006
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Last Update Date | 07/09/2018
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Provider Practice Location Address
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Address Line | 23000 HENDERSON ROAD
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City | COVELO
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State | CA
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Zip | 95428-0247
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Country | US
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Telephone | 707-983-6648
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Fax | 707-983-6649
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Provider Business Mailing Address
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Address Line | PO BOX 247
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City | COVELO
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State | CA
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Zip | 95428-0247
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Country | US
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Telephone | 707-983-6648
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Fax | 707-983-6649
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY 12983
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License Number State | CA
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