Provider Demographics
NPI:1174002703
Name:MACK, LAUREN ROSE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ROSE
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11425 DRAPPO AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-6083
Mailing Address - Country:US
Mailing Address - Phone:702-576-8586
Mailing Address - Fax:
Practice Address - Street 1:5803 W CRAIG RD STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2537
Practice Address - Country:US
Practice Address - Phone:702-901-5200
Practice Address - Fax:702-901-5201
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NV02112512103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician