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General NPI Number Information
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NPI Number | 1780740563
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Entity Type | Individual
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Provider Name | PAUL JEFFREY MACK CHTP, ED.D, MS, BA
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Gender | Male
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Dates
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Enumeration Date | 12/28/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1015 MCCAUSLAND AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63117-1924
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Country | US
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Telephone | 314-781-5050
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Fax |
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Provider Business Mailing Address
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Address Line | 2960 MILTON BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63104-1636
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Country | US
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Telephone | 314-497-5247
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | 2504
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License Number State | CO
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