Provider Demographics
NPI:1346316700
Name:MACK, DAVID CHARLES (LICSW(MA), LCSW(AZ))
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CHARLES
Last Name:MACK
Suffix:
Gender:M
Credentials:LICSW(MA), LCSW(AZ)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7214 E CAMINO VECINO
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3416
Mailing Address - Country:US
Mailing Address - Phone:781-696-3711
Mailing Address - Fax:
Practice Address - Street 1:7214 E CAMINO VECINO
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3416
Practice Address - Country:US
Practice Address - Phone:781-696-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1117481041C0700X
AZLCSW-141091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA111748OtherLICSW