Provider Demographics
NPI:1376118208
Name:MACK'S EMPOWERMENT COUNSELING
Entity Type:Organization
Organization Name:MACK'S EMPOWERMENT COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CORESAIR
Authorized Official - Middle Name:ANTON
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MSED, LCPC, NCC
Authorized Official - Phone:224-407-5019
Mailing Address - Street 1:220 E HILLCREST DR APT 4210
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2452
Mailing Address - Country:US
Mailing Address - Phone:847-421-4613
Mailing Address - Fax:
Practice Address - Street 1:164 DIVISION ST STE 716
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-5534
Practice Address - Country:US
Practice Address - Phone:224-407-5019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health