Provider Demographics
NPI:1003101817
Name:MACK, BEVERLY SHAW (LBSW)
Entity Type:Individual
Prefix:MISS
First Name:BEVERLY
Middle Name:SHAW
Last Name:MACK
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5631 HERON DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77033-3131
Mailing Address - Country:US
Mailing Address - Phone:281-460-9590
Mailing Address - Fax:713-278-9711
Practice Address - Street 1:6300 HILLCROFT ST STE 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-3005
Practice Address - Country:US
Practice Address - Phone:281-460-9590
Practice Address - Fax:713-278-9711
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11758171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator