Provider Demographics
NPI:1114104478
Name:MACK, CECELIA MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:CECELIA
Middle Name:MARIE
Last Name:MACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:CECELIA
Other - Middle Name:MARIE
Other - Last Name:NASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1249 WATERTON TRL
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-3689
Mailing Address - Country:US
Mailing Address - Phone:770-947-6307
Mailing Address - Fax:
Practice Address - Street 1:265 BOULEVARD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1208
Practice Address - Country:US
Practice Address - Phone:404-730-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004994101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional