Provider Demographics
NPI:1316197791
Name:MACK, TARI N (PHD)
Entity Type:Individual
Prefix:DR
First Name:TARI
Middle Name:N
Last Name:MACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 CHURCH ST
Mailing Address - Street 2:SUITE 415
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:773-307-8148
Mailing Address - Fax:773-508-2740
Practice Address - Street 1:636 CHURCH ST
Practice Address - Street 2:SUITE 415
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:773-307-8148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007514103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling