Provider Demographics
NPI:1346617842
Name:MACK, TAMEKA (MAC, NCC, LPC, CPCS)
Entity Type:Individual
Prefix:
First Name:TAMEKA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:MAC, NCC, LPC, CPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 CHISHOLM TRL
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-3708
Mailing Address - Country:US
Mailing Address - Phone:478-957-9221
Mailing Address - Fax:478-254-7826
Practice Address - Street 1:611 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2834
Practice Address - Country:US
Practice Address - Phone:478-254-0481
Practice Address - Fax:478-254-9723
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008399101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003198369AMedicaid