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NPI Code Detail

MEDICARE: MARY LYNNE MACK PHD LLC

MEDICARE: MARY LYNNE MACK PHD LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical Psychologist2598-057WI

General Provider Information

NPI Number : 1639415078
Entity Type Code : Organization
Provider Name (Legal Business Name) : MARY LYNNE MACK PHD LLC
Provider Business Mailing Address
First Line : 4600 E WASHINGTON ST STE 300
Second Line :
City : PHOENIX
State : AZ
Zip : 85034-1908
Country : US
Telephone Number : 480-737-6076
Fax Number :
Provider Business Practice Location Address
First Line : 4600 E WASHINGTON ST STE 300
Second Line :
City : PHOENIX
State : AZ
Zip : 85034-1908
Country : US
Telephone Number : 480-737-6076
Fax Number :
Authorized Official
Title or Position : PSYCHOLOGIST
Name : DR. MARY LYNNE MACK
Credential : PH.D.
Telephone Number : 262-391-2551
Provider Enumeration Date : 12/12/2012
Last Update Date : 01/09/2026

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