Provider Demographics
NPI:1114075736
Name:MACK, JOSEPH
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:MACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 GARRETT RD
Mailing Address - Street 2:APT. F312
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-4472
Mailing Address - Country:US
Mailing Address - Phone:484-454-8700
Mailing Address - Fax:484-454-8710
Practice Address - Street 1:2000 OLD WEST CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2712
Practice Address - Country:US
Practice Address - Phone:484-454-8700
Practice Address - Fax:484-454-8710
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004107101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor