Provider Demographics
NPI:1376314583
Name:MACK, COLUMBIA
Entity Type:Individual
Prefix:MR
First Name:COLUMBIA
Middle Name:
Last Name:MACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SEVERANCE CIR STE 705
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-1590
Mailing Address - Country:US
Mailing Address - Phone:216-260-9017
Mailing Address - Fax:216-260-9038
Practice Address - Street 1:5 SEVERANCE CIR STE 705
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1590
Practice Address - Country:US
Practice Address - Phone:216-260-9017
Practice Address - Fax:216-260-9038
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health